Subxiphoid

The ideal subxiphoid view includes all four chambers of the heart. The SX should be performed in cardiac presets, but for the RUSH and FAST it is done in abdominal presets to allow rapid imaging of both abdominal and heart in an unstable patient.

Transducer placement (Figure 1)

Overhand grip
Transducer 2 cm below the xiphoid process
Directed underneath the ribcage, towards the patient’s left shoulder (2 o-clock position, angle typically less the 20 
May need to increase depth to 20 cm
Slightly rock the transducer under the sternum, and once under the sternum tilt the face up to open the left ventricle

Orientation Cardiac Presets (Figure 3, Video 1)

The left hepatic lobe will be viewed in the near field of the image (Figure 3)
The subxiphoid four chamber view of the heart can be found deep to the liver (indicator on the right of the screen)

Orientation Abdominal Presets for FAST and RUSH (Figure 4, Video 2)

Abdominal presets are ideal for visceral imaging, not the rapidly moving heart. The liver will appear smoother and more resolved then it does in cardiac presets. But the moving heart will appear less clear and may look dysfunctional. The FAST and RUSH use abdominal presets to allow rapid imaging of both the heart and abdomen. If a more complete cardiac assessment is needed, then cardiac presets should be used.
Transducer grove is towards the patient’s right (indicator on the left side of the screen)

Tip

This view allows global assessment of LV and RV functions

Figures and Clips

Figure 1 - Transducer Placement

Figure 2 - Orientation

Figure 3 - Ideal Subxiphoid - Cardiac Preset

Figure 4 - Ideal Subxiphoid - Abdominal Preset

Clip 1 - Subxiphoid with Cardiac Preset

Clip 2 - Subxiphoid with Abdominal Preset

References

Moore, Christopher L., and Joshua A. Copel. “Point-of-care ultrasonography.” New England Journal of Medicine 364.8 (2011): 749-757.