emergency cardiac ultrasound: “questions” stephanie j. doniger, md faap

EmergencyCardiac Ultrasound:

“Questions”

Stephanie J. Doniger, MD FAAP

Emergency Cardiac US

Focused questions: heart, pericardium

Potentially life-threatening conditions

Yes-No questions

Questions

Is cardiac activity present?

Global cardiac hyper/hypo -kinesis?

Is there a pericardial effusion?

Tamponade?

Abnormal Cardiac US

Cardiac arrest, asystole

Pericardial Fluid

Hemopericardium

Cardiac Tamponade

Cardiac ActivitySonographic asystole

Absence of ventricular contraction, M-mode

PEA eval.

*32% w/cardiac contractions

No pts w/cardiac standstill had ROSC

73% w/contractions had ROSC

Prognosis; stop resuscitative efforts?*Salen, et al. Can cardiac sonography and capnography be used independently and in combination to predict

resuscitation outcomes? Acad Emerg Med 8:610-615, 2001

M-Mode

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Wall Motion

LV dysfunction

Abnormal wall function

Abnormal ventric emptying/relaxation

Hypokinesia, akinesis, dyskinesia (paradoxic)

Hypokinesia

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Pericardial FluidPresence of anechoic fluid @ pericardial space

Local & systemic d/o’s, trauma, idiopathic

Acute vs. chronic

Echogenic/gray, swirling

Pus, blood + fibrin, malignant

Up to 50 cc may be physiologic

Pericardial Effusions

SmallModerat

eLarge

LocationPosteriorInferior to

LV

Extends to apex

Circumscribes heart

*Meas. @ Diastole <10 mm

10-15 mm

>15 mm

*maximal width of pericardial stripe

Pericardial EffusionSubxiphoid

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Pericardial EffusionPSSA

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Pericardial Effusion:Penetrating Trauma

100% Sensitivity (Plummer, 1992)

Reduced time to Dx & Disposition

42.4 min vs. 15.5 min

Improved survival

57.1 % vs. 100%

Randazzo MR et al. Accuracy of emergency physician assessment of LV ejection fraction and central venous pressure using echocardiography. Acad Emerg Med 10:973-977, 2003

Pericardial Effusion:Atraumatic

103/515 high-risk criteria

Unexplained hypotension/dyspnea, CHF, cancer, uremia, lupus or pericarditis

97.5% accuracy of bedside ECHO (EP)

Madavia, et al. Bedside echocardiography by emergency physicians. Ann Emerg Med 38: 377-382, 2001

NOT Pericardial Effusions

Pericardial fat pad

Anterior

Pleural effusions

Intraabdominal fluid

TamponadeCompression of the heart by blood/fluid btwn myocardium & pericardium

Rate of fluid accumulation > amt fluid

As little as 150 mL

Clinical diagnosis

Clinical picture; triad muffled heart tones, hypotension, JVD

Hemodynamics

Tamponade: US

Circumferential pericardial effusion

“Scalloping” of RV

Diastolic collapse of RV (or RA)

Swinging heart

CCW rotational movement

Dilated IVC without inspiratory variation

Tamponade

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are needed to see this picture.

Tamponade

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Do you have questions?