Written by Chris Thom
Spoon Feed
In this review of POCUS echocardiograms, there was a significant distance between the AHA-recommended compression location of the lower third of the sternum and the actual location of the left ventricle.
Are we compressing the correct spot?
This study included non-cardiac-arrest adult patients who were undergoing POCUS echocardiograms as part of their routine clinical care in the ED. The distance from the lower third of the sternum to the mid LV on echo was measured on the chest wall. The mid LV was denoted by the papillary muscles.
A total of 110 patients were included in the analysis. The average sternum-to-LV distance was 4.85 cm (SD ± 1.44), with age ≥ 80 having a greater distance at 5.50 cm (SD ± 1.41). Male gender was associated with a slightly higher mean distance, as was obesity.
How will this change my practice?
There is emerging literature surrounding this topic of hand location and chest compressions. We’ve seen that there may be advantages to ensuring that the LV is compressed vs. the LV outflow tract or the aorta. Much of this is in the TEE literature, which allows active monitoring of the heart during chest compressions. Other considerations include whether compression off the sternum and over the ribs would lead to untoward or adverse results. Thus far, I have adopted the practice of using TEE to encourage higher or lower hand placement to ensure LV compression during arrest, while still remaining midline and over the sternum.
POCUS Pro-Tips and Clips
The authors of this paper highlight a few protocols, such as the CASA protocol, that provide a framework for how to efficiently perform TTE during cardiac arrest. I’ve found it additionally helpful to have the probe on the subcostal region and already imaging before the pause in chest compressions. This can allow for more efficient imaging, as you save the 2–3 seconds of getting the probe initially positioned and in place. If the subcostal location is not providing a window to the heart, I’d be very quick to jump up to the parasternal long window and then use that as “home base” for any additional echo evaluations during the course of the arrest.
Source
Mismatch between left ventricle location and standard cardiopulmonary resuscitation hand placement: A transthoracic POCUS study. Am J Emerg Med. 2026 Jan;99:471-476. doi: 10.1016/j.ajem.2025.11.003. Epub 2025 Nov 6. PMID: 41237704.
