The 5 POCUS cardiac views
Why examiners ask this
Transthoracic point-of-care views show up twice in the OSCE: as loops in the monitors station and as views I must acquire in the ultrasound station. The outline names five,1 and each answers a different bedside question: how is the LV squeezing, is the RV big, is there fluid around the heart, is the patient empty. Naming the view and the window before the finding is the scored step. It tests application of knowledge and organization.
The 60-second answer
I use a phased-array probe at 1–5 MHz on the cardiac preset, which puts the screen marker on the right. For any loop I first say the window: parasternal, apical or subcostal. Then I say the plane: long-axis, short-axis or four-chamber. Then I name the anchor structures that prove it. Only then do I describe the finding: LV size and squeeze, RV size relative to the LV, the pericardium, and the IVC. If the parasternal window is poor because of lung or positive-pressure ventilation, I go subcostal, which is the best window in a ventilated or arrested patient because the liver is the acoustic window. Every answer ends with what the finding changes: fluid, inotrope, drain or decompress.
Decision points and the "why"
The five outline views, with probe position and the features that identify each.
| View | Probe position and marker | Identifying features | Main question it answers |
|---|---|---|---|
| Parasternal long-axis | Left sternal border, 3rd–4th space, marker to right shoulder | RVOT at top, LV, mitral and aortic valves, LA, descending aorta behind the LA | LV function, effusion versus pleural fluid, aortic root |
| Parasternal short-axis, mid-papillary | Same spot, rotate 90° clockwise, marker to left shoulder | Round LV with two papillary muscles, crescent RV | Global and regional LV function, septal "D" sign |
| Apical four-chamber | Point of maximal impulse, ~5th space, marker to the patient's left | Apex at top, four chambers, LV on the right of screen | RV:LV ratio, global function, valve color |
| Subcostal four-chamber | Below the xiphoid, probe flat, marker to the patient's left, aimed at left shoulder | Liver at top, RV nearest the probe, four chambers | Effusion, RV collapse, cardiac activity in arrest |
| Subcostal IVC | From subcostal four-chamber, rotate marker to the head | IVC entering the RA, hepatic vein joining | Volume status, RA pressure, plethora in tamponade |
- Parasternal long-axis for effusion versus pleural fluid — the descending aorta is the landmark. Pericardial fluid tracks anterior to it, between the aorta and the heart; a left pleural effusion lies posterior and lateral to it.2 That single distinction changes whether I call tamponade.
- Parasternal short-axis for the septum — a septum that flattens into a "D" in diastole means RV volume overload; in systole as well means pressure overload. That pushes me toward PE or RV failure and away from fluid.
- Apical four-chamber for RV size — an RV basal diameter over 41 mm is dilated;3 an RV as large as or larger than the LV is severe dilation. That is the view I use before I give fluid to a hypotensive patient with a high CVP.
- Subcostal for the unstable patient — I can scan it during CPR pauses of less than 10 seconds without interfering with compressions, and it shows a large effusion and cardiac standstill.4
- IVC measured correctly — I measure 1–2 cm from the RA junction, supine, in long axis, perpendicular to the vessel,3 so I do not mistake the aorta or a tangential cut for the cava.
The complication they will inject
The loop is a subcostal view in a hypotensive patient after a central line. The facilitator asks what I see. I say: "Subcostal four-chamber; an anechoic circumferential collection around the heart; the right ventricle collapses in diastole." Then the unifying diagnosis: tamponade, most likely from vessel or cardiac perforation. Then the action: tell the team, give fluid, keep the heart rate up, avoid large tidal volumes, and prepare for ultrasound-guided pericardiocentesis or surgical drainage. The harder variant shows the same dark space only in the parasternal long-axis, posterior to the descending aorta. That is a left pleural effusion, and the right answer is to say so rather than drain the pericardium.
Pitfalls that cost points
- Calling a pleural effusion pericardial because I never looked for the descending aorta.
- Measuring the aorta and calling it the IVC; the aorta is pulsatile, thick-walled and left of midline.
- Judging RV size from a foreshortened apical view.4
- Calling epicardial fat an effusion; fat is mostly anterior, brighter than myocardium, and moves with the heart.2
- Describing a finding without naming the window and plane first.
Rapid-why
Q: Why is the subcostal window best during mechanical ventilation? A: Inflated lung covers the parasternal and apical windows, but the liver gives a fluid-filled path to the heart from below. Parasternal and subcostal windows are also the easiest for non-experts to obtain reliably.4
Q: What does a "D-shaped" LV mean? A: The RV is pressure- or volume-loaded enough to push the septum toward the LV, which points to PE, RV infarction or pulmonary hypertension.
Q: How do I tell the IVC from the aorta? A: The IVC enters the RA, receives a hepatic vein, varies with respiration and lies to the patient's right.
Q: Which probe do I choose? A: Phased array, because its small footprint fits between ribs and its low frequency reaches 16–20 cm.
Numbers to know
| Item | Value |
|---|---|
| Probe | Phased array, 1–5 MHz |
| Typical depth | 16–20 cm (parasternal ~16 cm) |
| RV basal diameter | >41 mm dilated;3 RV ≥ LV severe |
| IVC measurement point | 1–2 cm from the RA junction3 |
| CPR pulse-check scan | <10 s |
| Views in the outline | 5 POCUS cardiac1 |
Links
- The 11 TEE views, POCUS image acquisition: probe positions and Doppler sectors, Volume status, IVC and fluid responsiveness, Pericardial effusion and tamponade, Pulmonary embolism and air embolism (coming)
- Atlas: The 11 TEE views
- ASE Focused Cardiac Ultrasound Recommendations (2013); ASE/EACVI Chamber Quantification (2015)
Sources
- 1.APPLIED Exam Objective Structured Clinical Examination (OSCE) Content Outline · ABA · theaba.org
- 2.Clinical Recommendations for Multimodality Cardiovascular Imaging of Patients with Pericardial Disease · ASE, 2013 · asecho.org
- 3.Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI · ASE/EACVI, 2015 · asecho.org
- 4.Focused Cardiac Ultrasound: Recommendations from the American Society of Echocardiography · ASE, 2013 · asecho.org
Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.