cardiac ultrasound in emergency medicine
DESCRIPTION
Cardiac Ultrasound in Emergency Medicine. Anthony J. Weekes MD, RDMS Sarah A. Stahmer MD For the SAEM US Interest Group. Primary Indications. Thoraco-abdominal trauma Pulseless Electrical Activity Unexplained hypotension Suspicion of pericardial effusion/tamponade. Secondary Indications. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/1.jpg)
Cardiac Ultrasound in Cardiac Ultrasound in Emergency MedicineEmergency Medicine
Anthony J. Weekes MD, RDMSSarah A. Stahmer MD
For the SAEM US Interest Group
![Page 2: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/2.jpg)
Primary IndicationsPrimary Indications
Thoraco-abdominal trauma
Pulseless Electrical Activity
Unexplained hypotension
Suspicion of pericardial
effusion/tamponade
![Page 3: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/3.jpg)
Secondary IndicationsSecondary Indications
Acute Cardiac Ischemia
Pericardiocentesis
External pacer capture
Transvenous pacer placement
![Page 4: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/4.jpg)
Main Clinical QuestionsMain Clinical Questions
What is the overall cardiac wall motion?
Is there a pericardial effusion?
![Page 5: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/5.jpg)
Cardiac probe selectionCardiac probe selection
Small round footprint for scan between ribs
2.5 MHz: above average sized patient
3.5 MHz: average sized patient
5.0 MHz: below average sized patient or child
![Page 6: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/6.jpg)
Main cardiac viewsMain cardiac views
Parasternal Subcostal Apical
![Page 7: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/7.jpg)
Wall MotionWall Motion
NormalHyperkineticAkineticDyskinetic: may fail
to contract, bulges outward at systole
Hypokinetic
![Page 8: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/8.jpg)
OrientationOrientation
Subcostal or subxiphoid viewBest all around imaging windowGood for identification of:
– Circumferential pericardial effusion– Overall wall motion
Easy to obtain – liver is the acoustic window\
![Page 9: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/9.jpg)
Subcostal ViewSubcostal View
Most practical in trauma setting
Away from airway and neck/chest procedures
![Page 10: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/10.jpg)
Subcostal ViewSubcostal View
Liver as acoustic window
Alternative to apical 4 chamber view
![Page 11: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/11.jpg)
Subcostal ViewSubcostal View
![Page 12: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/12.jpg)
Subcostal ViewSubcostal View
![Page 13: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/13.jpg)
Subcostal ViewSubcostal View
Angle probe right to see IVC
Response of IVC to sniff indicates central venous pressure
No collapse– Tamponade– CHF– PE– Pneumothorax
![Page 14: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/14.jpg)
Parasternal ViewsParasternal Views
Next best imaging windowGood for imaging LVComparing chamber sizesLocalized effusionsDifferentiating pericardial from pleural
effusions
![Page 15: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/15.jpg)
Parasternal Long AxisParasternal Long Axis
Near sternum3rd or 4th left intercostal spaceMarker pointed to patient’s right
shoulder (or left hip if screen is not reversed for cardiac imaging)
Rotate enough to elongate cardiac chambers
![Page 16: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/16.jpg)
Parasternal Long AxisParasternal Long Axis
![Page 17: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/17.jpg)
Parasternal Long Axis ViewParasternal Long Axis View
![Page 18: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/18.jpg)
Parasternal Short Axis Parasternal Short Axis
Obtained by 90° clockwise rotation of the probe towards the left shoulder (or right hip)
Sweep the beam from the base of the heart to the apex for different cross sectional views
![Page 19: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/19.jpg)
Parasternal Short Axis ViewParasternal Short Axis View
![Page 20: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/20.jpg)
Parasternal Short AxisParasternal Short Axis
![Page 21: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/21.jpg)
Apical ViewApical View
Difficult view to obtainAllows comparison of ventricular
chamber sizeGood window to assess septal/wall
motion abnormalities
![Page 22: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/22.jpg)
Apical ViewsApical Views
Patient in left lateral decubitus position
Probe placed at PMI
Probe marker at 6 o’clock (or right shoulder)
4 chamber view
![Page 23: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/23.jpg)
Apical 4 chamber viewApical 4 chamber view Marker pointed to
the floor Similar to
parasternal view but apex well visualized
Angle beam superiorly for 5 chamber view
![Page 24: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/24.jpg)
Apical 4 chamber viewApical 4 chamber view
![Page 25: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/25.jpg)
Apical 2 chamber viewApical 2 chamber view
Patient in left lateral decubitus position
Probe placed at PMI
Probe marker at 3 o’clock
2 chamber view
![Page 26: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/26.jpg)
Apical 2 chamber viewApical 2 chamber view Good look at inferior and anterior walls
![Page 27: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/27.jpg)
Apical 2 chamber viewApical 2 chamber view
From apical 4, rotate probe 90° counterclockwise
Good view for long view of left sided chambers and mitral valve
![Page 28: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/28.jpg)
Abnormal findingsAbnormal findings
Pericardial Effusion
![Page 29: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/29.jpg)
Case PresentationCase Presentation
45 year old male presents with SOB and dizziness for 2 days. He has a long smoking history, and has complained of a non-productive cough for “weeks”
Initial VS are BP 88/palp, HR 140PE: Neck veins are distendedChest: Clear, muffled heart soundsBedside sonography was performed
![Page 30: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/30.jpg)
![Page 31: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/31.jpg)
Echo free space around the heartEcho free space around the heart
Pericardial effusionPleural effusionEpicardial fat (posterior and/or
anterior)Less common causes:
– Aortic aneurysm– Pericardial cyst– Dilated pulmonary artery
![Page 32: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/32.jpg)
Size of the Pericardial Size of the Pericardial EffusionEffusion
Not PreciseSmall: confined to posterior space,
< 0.5cmModerate: anterior and posterior,
0.5-2cm (diastole)Large: > 2cm
![Page 33: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/33.jpg)
Pericardial Fluid: Subcostal Pericardial Fluid: Subcostal
![Page 34: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/34.jpg)
Clinical features of Clinical features of Pericardial effusionPericardial effusion
Pericardial fluid accumulation may be clinically silent
Symptoms are due to:– mechanical compression of adjacent
structures– Increased intrapericardial pressure
![Page 35: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/35.jpg)
Pericardial Pericardial Effusion:AsymptomaticEffusion:Asymptomatic
Up to 40% of pregnant womenChronic hemodialysis patients
– one study showed 11% incidence of pericardial effusion
AIDSCHFHypoproteinemic states
![Page 36: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/36.jpg)
Symptoms of Pericardial Symptoms of Pericardial EffusionEffusion
Chest discomfort (most common)Large effusions:
– Dyspnea– Cough– Fatigue– Hiccups– Hoarseness– Nausea and abdominal fullness
![Page 37: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/37.jpg)
Cardiac TamponadeCardiac Tamponade
Increased intracardiac pressures
Limitation of ventricular diastolic filling
Reduction of stroke volume and cardiac output
![Page 38: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/38.jpg)
Ventricular collapse in Ventricular collapse in diastolediastole
![Page 39: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/39.jpg)
TamponadeTamponade
![Page 40: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/40.jpg)
HypotensionHypotension
![Page 41: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/41.jpg)
Abnormal findingsAbnormal findings
Is the cause of hypotension cardiac in
etiology?
Is it due to a pericardial effusion?
Is is due to pump failure?
![Page 42: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/42.jpg)
Unexplained HypotensionUnexplained Hypotension
Cardiogenic shock – Poor LV contractility
Hypovolemia– Hyperdynamic ventricules
Right ventricular infarct/large pulmonary embolism– Marked RV dilitation/hypokinesis
Tamponade– RV diastolic collapse
![Page 43: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/43.jpg)
Cardiogenic shockCardiogenic shock
Dilated left ventricle
Hypocontractile walls
![Page 44: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/44.jpg)
HypovolemiaHypovolemia
Small chamber filling size
Aggressive wall motion
Flat IVC or exaggerated collapse
with deep inspiration
![Page 45: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/45.jpg)
Massive PE or RV infarctMassive PE or RV infarct
Dilated Right ventricle
RV hypokinesis Normal Left
ventricle function Stiff IVC
![Page 46: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/46.jpg)
Case presentation ? overdose Case presentation ? overdose
27 yo f brought in with “passing out” after night of heavy drinking.
Complaining of inability to breathe!PE: Obese f BP 88/60 HR 123 Ox
78% Chest: clearExt: No edemaBedside sonography was performed
![Page 47: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/47.jpg)
![Page 48: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/48.jpg)
![Page 49: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/49.jpg)
Chest pain then codeChest pain then code
55 yo male suffered witnessed Vfib arrest in the ED
ALS protocol - restoration of perfusing rhythm
Persistant hypotensionED ECHO was performed
![Page 50: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/50.jpg)
![Page 51: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/51.jpg)
![Page 52: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/52.jpg)
R sided leads
![Page 53: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/53.jpg)
Non Traumatic Non Traumatic ResuscitationResuscitation
![Page 54: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/54.jpg)
Direct VisualizationDirect VisualizationIs there effective myocardial
contractility?– Asystole– Myocardial “twitch”– Hypokinesis– Normal
Is there a pericardial effusion?
![Page 55: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/55.jpg)
ECHO in PEAECHO in PEA
Perform ECHO during “quick look” and in pulse checks
Change management based on “positive” findings
Pericardial tamponade– Pericardiocentesis
Hyperdynamic cardiac wall motion– Volume resuscitate
![Page 56: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/56.jpg)
ECHO in PEAECHO in PEA
RV dilatation– Hypoxic?? – Likely PE– ECG – IMI with RV infarct?
Profound hypokinesis– Inotropic support
Asystole– Follow ACLS protocols (for now)– Early data suggesting poor prognosis
![Page 57: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/57.jpg)
ECHO in PEAECHO in PEA
False positive cardiac motion
– Transthoracic pacemaker
– Positive pressure ventilation
![Page 58: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/58.jpg)
Case presentationCase presentation
Morbidly obese female with severe asthma Intubated for respiratory failure Subcutaneous emphysema developed Bilateral chest tubes placed Persistent hypotension at 90/palp Dependent mottling noted ECHO was performed
![Page 59: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/59.jpg)
Ineffective cardiac Ineffective cardiac contractionscontractions
![Page 60: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/60.jpg)
Optimizing PerformanceOptimizing Performance
Assessing capture by transthoracic pacemaker
Pericardiocentesis
Transvenous pacemaker placement
![Page 61: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/61.jpg)
Optimizing PerformanceOptimizing Performance
Assessment of capture by transthoracic pacemaker
Ettin D et al: Using ultrasound to determine external pacer capture JEM 1999
![Page 62: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/62.jpg)
Case PresentationCase Presentation
70 yo f collapsed in lobby. She was brought into the ED apneic, hypotensive. She was quickly intubated and volume resuscitation begun.
VS: BP 80/50 HR 50 Afebrile Physical exam : Thin, minimally responsive f.
Clear lungs, nl heart sounds, abdomen slightly distended with decreased bowel sounds. No HSM, ? Pelvic mass
ECG: SB, LVH, no active ischemia
![Page 63: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/63.jpg)
Clinical questions?Clinical questions?
Why is she hypotensive?Volume loss
?Ruptured AAAPump failureBedside sonography was performed
while we were waiting for the “labs”
![Page 64: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/64.jpg)
Increase HR with PM “on”Increase HR with PM “on”
![Page 65: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/65.jpg)
What did this tell us?What did this tell us?
Normal wall motion
No pericardial/pleural effusion
Good capture with the transthoracic PM
![Page 66: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/66.jpg)
Asystole w/ Transthoracic PMAsystole w/ Transthoracic PM
![Page 67: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/67.jpg)
Optimizing performance Optimizing performance
Pericardiocentesis– Standard of care by cardiology/CT surgery
to use ECHO to guide aspiration
![Page 68: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/68.jpg)
US Guided- US Guided- PericardiocentesisPericardiocentesis Subcostal approach
– Traditional approach– Blind– Increased risk of injury to liver, heart
Echo guided– Left parasternal preferred for needle entry
or…– Largest area of fluid collection adjacent to
the chest wall
![Page 69: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/69.jpg)
Large pericardial effusionLarge pericardial effusion
![Page 70: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/70.jpg)
TechniqueTechnique
![Page 71: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/71.jpg)
Optimizing performanceOptimizing performance
Placement of transvenous pacemakerAguilera P et al: Emergency
transvenous cardiac pacing placement using ultrasound guidance. Ann Emerg Med 2000
![Page 72: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/72.jpg)
Untimely end Untimely end
30 yo brought in after he “fell out”Ashen m with no spontaneous
respirationsVS: No pulse, agonal rhythm on monitorIntubated/CPRTransvenous pacemaker placed, no
capture.ECHO showed
![Page 73: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/73.jpg)
![Page 74: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/74.jpg)
Penetrating Chest TraumaPenetrating Chest Trauma
![Page 75: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/75.jpg)
Penetrating Cardiac TraumaPenetrating Cardiac Trauma
Physician’s ability to determine whether there is a hemodynamically significant effusion is poor
Beck’s Triad – Dependent on patient cardiovascular status– Findings are often late
Determinants of hemodynamic compromise– Size of the effusion– Rate of formation
![Page 76: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/76.jpg)
Penetrating Cardiac InjuryPenetrating Cardiac InjuryEmergency department
echocardiography improves outcome in penetrating cardiac injury.
Plummer D et al. Ann Emerg Med. 1992
28 had ED echo c/w 21 without ED echo Survival: 100% in echo, 57.1% in nonecho Time to Dx: 15 min echo, 42 min nonecho
![Page 77: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/77.jpg)
Penetrating Cardiac InjuryPenetrating Cardiac Injury
The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study.
Rozycki GS: J Trauma. 1999
Pericardial scans performed in 261 patients Sensitivity 100%, specificity 96.9% PPV: 81% NPV:100% Time interval BUS to OR: 12.1 +/- 5.9 min
![Page 78: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/78.jpg)
Emergency Department Echocardiography Improves Outcome in Penetrating Cardiac Injury
Plummer D, et al. Ann Emerg Med 21:709-712, 1992.
“Since the introduction of immediate ED two-dimensional echocardiography, the time to diagnosis of penetrating cardiac injury has decreased and both the survival rate and neurologic outcome of survivors has improved.”
Penetrating Cardiac TraumaPenetrating Cardiac Trauma
![Page 79: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/79.jpg)
Stab wound to the chestStab wound to the chest
![Page 80: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/80.jpg)
Echocardiographic signs of rising intrapericardial pressure– Collapse of RV free walls– Dilated IVC and hepatic veins
Goal: Early detection of pericardial effusion– Develops suddenly or discretely– May exist before clinical signs develop
Salvage rates better if detected before hypotension develops
Penetrating Cardiac TraumaPenetrating Cardiac Trauma
![Page 81: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/81.jpg)
Technical ProblemsTechnical Problems
Subcutaneous airPneumopericardiumMechanical ventilation Scanning limited by:
– Pain/tenderness– Spinal immobilization– Ongoing procedures
![Page 82: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/82.jpg)
Technical Problems Technical Problems
Narrow intercostal spacesObesityMuscular chest COPDCalcified rib cartilagesAbdominal distention
![Page 83: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/83.jpg)
Sonographic PitfallsSonographic Pitfalls
Pericardial versus pleural fluid
Pericardial clot
Pericardial fat
![Page 84: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/84.jpg)
Pericardial or Pleural FluidPericardial or Pleural FluidLeft parasternal long axis:
– Pericardial fluid does not extend posterior to descending aorta or left atrium
Subcostal: – No pleural reflection between liver and R
sided chambers– A pleural effusion will not extend between
to RV free wall and the liver
![Page 85: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/85.jpg)
Pleural and Pericardial fluidPleural and Pericardial fluid
![Page 86: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/86.jpg)
Pleural effusionPleural effusion
![Page 87: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/87.jpg)
Blunt Cardiac TraumaBlunt Cardiac Trauma
Cardiac contusion
Cardiac rupture
Valvular disruption
Aortic disruption/dissection
![Page 88: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/88.jpg)
Blunt Cardiac TraumaBlunt Cardiac Trauma
Pericardial effusionAssess for wall motion abnormality
– RV dyskinesis (takes the first hit)Assess thoracic aorta:
– Hematoma– Intimal flap– Abnormal contour
Valvular dysfunction or septal rupture
![Page 89: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/89.jpg)
Cardiac ContusionCardiac Contusion
Akinetic anterior RV wall
Small pericardial effusion
Diminished ejection fraction
![Page 90: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/90.jpg)
RV ContusionRV Contusion
![Page 91: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/91.jpg)
Blunt Cardiac TraumaBlunt Cardiac Trauma
Assess thoracic aorta– Hematoma– Intimal flap– Abnormal contour– Requires TEE and expertise!
Valvular dysfunction or septal rupture– Requires expertise beyond our scope
![Page 92: Cardiac Ultrasound in Emergency Medicine](https://reader036.vdocuments.us/reader036/viewer/2022062408/56813fbf550346895daa9c64/html5/thumbnails/92.jpg)
SummarySummary
Bedside ECHO can help assess:– Overall cardiac wall motion– Identify clinically significant pericardial effusions
Useful in the assessment of the patient with:– Unexplained hypotension– Dyspnea– Thoracic trauma