FREE stands for Focused Rapid Echocardiographic Evaluation.

The FREE focuses on obtaining functional hemodynamic data to guide decision making regarding fluid management, inotropic support, and vasopressor use.

The primary indication is complex shock and respiratory Failure.

FREE Protocol and Workflow

1. Collect clinical data

  • Height, weight, HR, blood pressure
  • See Education/FREE/Measurements

2. Get FREE images, perform calculations, and determine hemodynamic profile

  • Normal X 3
  • Vasodialated / High-Output
  • Hummingbird
  • Dysfunctional

3. Determine best fluid management strategy

  • This patient at this time
  • Fluid liberal or Fluid conservative

4. Consider treatment inotropic, vasoactive and fluid therapies

  • Based on fluid strategy and hemodynamic profiles

Exam setup

  • Phased-array probe and a cardiac preset/exam for all imaging except lung
  • Lung presets/exam for lung imaging
  • If measuring hepatic venous flow apply ECG leads
  • All clips should be 5 seconds or >/= 5 heart beats

FREE Windows and Assessments

1. Parasternal Long Axis (Figure 1)

Save 2D clip (Video 1)

  • Assess LV function
  • Assess RV function
  • Look for Aortic Valve (AV) stenosis

Bonus: Save color flow Doppler (CFD) Clip

  • Look for Mitral valve regurgitation
  • Look for AV Insufficiency

Measure/save left ventricular outflow tract diameter (LVOTD) (Figure 2)

  • Used for stroke volume (SV) and cardiac output (CO)
  • If unable to measure, consider modified body surface area (BSA) to estimate LVOTD

Modified Body Surface Area to estimate LVOTD

  • If BSA < 1.8 M2 use 1.8 cm to estimate LVOTD
  • If BSA 1.8-2.2 use BSA in cm to estimate LVOTD
  • If BSA > 2.2 use 2.2 cm to estimate LVOTD

2. Parasternal Short Axis (Figure 3)

Save clip at the papillary level (Video 2)

  • Assess LV function
  • Assess RV function
  • Look for D shaped LV

3. Apical 4 (Figure 4)

Save 2D clip Video 3

Save CFD clip

Measure/save TAPSE with M-mode (Figure 5, Figure 6)

Bonus: if concern for elevated PA pressure

  • Assess for tricuspid regurgitant jet (TRJ) (Figure 7, 8)
  • Measure/save TRJ peak flow (used for estimating systolic pulmonary artery pressure )

4. Apical 5

Save 2D clip

Pulsed wave Doppler through the LVOT -Measure/save the LVOT velocity time integral (VTI) (Figure 9, 10) -Used for SV/CO

Bonus: if in sinus rhythm (Figure 11, 12)

  • Increase sweep speed to 75 mm/sec
  • Measure peak to peak stroke volume variation
  • Used for respiratory stroke volume variation (SVV)

Bonus if concern for aortic stenosis (Figure 13)

  • Assess/save wave Doppler through the AV

5. Subxiphoid

Use only if unable to assess other windows

Consider if pericardial effusion seen

6. Liver

Save 2D clip IVC (Video 4, Figure 14)

PW through hepatic vein (Figure 15, 16)

  • Assess flow pattern (Figure 17)
  • Used to assess for elevate right atrial pressure (RAP)

PW through a portal vein

  • Assess for portal pulsatility (Figure 18)
  • Used to assess for elevated RAP and portal hypertension

7. Lung

Change to lung or abdominal presets/exam type

Left anterior chest upper, middle, lower (Figure 19)

Right anterior chest upper, middle, lower

  • Save clips
  • Assess for B-lines


Figure 1 - Probe Placement in PLA Window

Figure 2 - Measuring LVOT Diameter

Figure 3 - Probe Placement in PSA Window

Figure 4 - Probe Placement in Apical 4 & 5 Windows

Figure 5 - Apical 4 TAPSE Measurement

Figure 6 - M-mode to Measure TAPSE

Figure 7 - TR jet

Figure 8 - CW TR jet

Figure 9 - LV VTI

Figure 10 - LV PW VTI

Figure 11 - SVV measurement

Figure 12 - SVV VTI

Figure 13 - Aortic Stenosis

Figure 14 - IVC Variation

Figure 15 - Hepatic and Portal Veins

Figure 16 - Hepatic flow with elevated RAP

Figure 17 - Normal Portal Flow

Figure 18 - Changes with elevated portal pressure

Figure 19 - Transducer Placement for FREE


Clip 1 - PLA Window

Clip 2 - PAS Window at Papillary Level

Clip 3 - Apical 4 Window

Clip 4 - Subxiphoid Window showing IVC

Clip 5 - Apical 5 Window


Murthi, S. B., et al. “Focused comprehensive, quantitative, functionally based echocardiographic evaluation in the critical care unit is feasible and impacts care.” Military medicine 180.3 Suppl (2015): 74.

Glaser, Jacob J., et al. “Bridging the gap: Hybrid cardiac echo in the critically ill.” Journal of Trauma and Acute Care Surgery 81.5 (2016): S157-S161.'

Ferrada, Paula, et al. “Transthoracic focused rapid echocardiographic examination: real-time evaluation of fluid status in critically ill trauma patients.” Journal of Trauma and Acute Care Surgery 70.1 (2011): 56-64.