To obtain the PSL view, place the probe adjacent to the sternum (at the level of the nipple) with the probe marker facing the patient’s right shoulder (Fig. 1). If the standard cardiac structures are not visualized, we recommend sliding the ultrasound probe in a cephalad or caudal direction, while continuing to point the probe marker toward the patient’s right shoulder (Fig. 1). When the heart is identified, rotate the axis of the ultrasound probe until a view of the right ventricle, mitral valve, left ventricle, and descending thoracic aorta is obtained (Fig. 2). The clinician can ensure the lack of a pericardial effusion in the dependent position between the descending thoracic aorta and myocardium (Fig. 3). The clinician should then grossly evaluate cardiac function by looking at the gross squeeze/movement of the left ventricle. Visually estimating mitral valve E-point septal separation (EPSS), the minimum distance between the anterior leaflet and the interventricular septum in the PSL axis, is an alternative method to assess left ventricular systolic function.5 An EPSS of more than 0.7 cm correlates with an ejection fraction (EF) under 30%; however, this may not be accurate in cases of aortic insufficiency or mitral stenosis. In cases of severe systolic cardiac dysfunction, a distance greater than 1 cm between the anterior mitral valve leaflet and interventricular septum is not uncommon (Fig. 4). Again, gross estimation in conjunction with evaluation of mitral valve movement will allow the clinician to note poor cardiac systolic function.

After obtaining the best PSL view, rotate the probe 90 degrees until the probe marker faces the patient’s right iliac crest (Fig. 5) to obtain the PSS view. When an image of the left and right ventricular chambers is obtained, slightly move the probe toward the apex of the heart in order to be lower than the mitral valve for gross cardiac function.

The goal of the focused echo for the triple scan is not to determine mild functional cardiac impairment. Patients who are experiencing ADHF have moderate to severe cardiac dysfunction, and the sonographer should focus on the evaluation of gross dysfunction.

Focused Lung Ultrasound

The lung exam, as part of the triple scan protocol, evaluates the anterior and lateral chest. The anterior exam is most revealing for pneumothorax and alveolar interstitial syndrome (pulmonary edema) as identified by B-line artifacts arising from the pleura. The lateral exam, from the diaphragm to axilla, is best for detecting dependent pleural effusions.⁸ Position the probe longitudinally between two rib spaces starting at the mid-clavicular line (just below the clavicle) and scan caudally by slowly sliding the probe to the most dependent lung field (Fig. 6). Ensure the depth on the ultrasound screen is greater than 13 cm and increase the gain. The anterior lung exam answers two questions: the presence or absence of pneumothorax by assessing pleural sliding, and the presence of B-lines or A-lines from the pleura. We recommend scanning three or more ultrasound lung fields to determine the presence or absence of lung sliding (Fig. 6). Since the patient will often be sitting up, the exam will not be able to completely rule out the presence of a small apical pneumothorax (rarely if ever the cause of severe acute dyspnea in an ED patient). A-lines are hyperechoic, horizontal reverberation artifacts parallel to the pleura that represent normal or pathologically hyperaereted lungs. A-lines are commonly seen in patients with COPD and/or asthma (Fig. 7).³ B-lines are vertical reverberation artifacts arising from the pleura that are caused by thickened interlobular septa representing alveolar interstitial syndrome (AIS) (Fig. 7).⁹ Three or more B-lines visualized between a rib interspace are called “lung rockets” and indicate a positive scan for AIS. Their presence bilaterally defines pulmonary edema.³ The absence of B-lines in the anterior lung zones essentially rules out ADHF. The presence of poor systolic ejection fraction and bilateral B-lines in an acutely dyspneic ED patient indicates a high likelihood of the presence of ADHF.

IVC: Subxyphoid/Lateral Approach

The last part of the triple scan assesses IVC size and collapsibility. For the subxyphoid approach, the probe is positioned longitudinally just to the right of midline and rocked caudally to visualize the right atria if possible (Fig. 8). We recommend fanning the probe to the patient’s left to identify the aorta, and then back to the patient’s right to confirm the IVC. The IVC is differentiated from the aorta by observing its confluence with the hepatic vein and the right atrium. Once the IVC is identified, the provider assesses the collapsibility during inspiration, focusing approximately 2-3 cm caudal to the confluence of the hepatic vein. The IVC is categorized as plethoric (less than 15% collapse with inspiration), normal respiratory variability, or flat. We do not recommend measuring the IVC, but instead recommend looking for gross variability during respiration. A large, noncollapsible IVC suggests high right-sided pressures consistent with ADHF, but may also be present in cases of chronic pulmonary hypertension, large pulmonary embolus, valvular disorders such as pulmonary stenosis and mitral regurgitation, cardiac tamponade, and right-sided myocardial infarction.6 Fortunately, with the additional information obtained from both the focused echo and lung examination, the clinician is able to reduce diagnostic uncertainty.

Diastolic Dysfunction

Since diastolic dysfunction is a common cause of ADHF, can the triple scan be useful in this patient population?