cardiology ultrasound emergency
TRANSCRIPT
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Cardiac Ultrasound inCardiac Ultrasound in
Emergency MedicineEmergency Medicine
Anthony J. Weekes MD, RDMS
Sarah A. Stahmer MDFor the SAEM US Interest Group
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Secondary IndicationsSecondary Indications
Acute Cardiac Ischemia
Pericardiocentesis
External pacer capture
Transvenous pacer placement
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Main Clinical Questions
Main Clinical Questions
What is the overall cardiac wall motion?
Is there a pericardial effusion?
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Cardiac probe selectionCardiac probe selection
Small round footprintfor scan between ribs
2.5 MHz: aboveaverage sized patient
3.5 MHz: averagesized patient
5.0 MHz: belowaverage sized patientor child
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Main cardiac viewsMain cardiac views Parasternal
Subcostal
Apical
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WallM
otionWallM
otion Normal
Hyperkinetic
Akinetic
Dyskinetic: may fail
to contract, bulges
outward at systole
Hypokinetic
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Orientation
Orientation
Subcostal or subxiphoid view
Best all around imaging window
Good for identification of:
± Circumferential pericardial effusion
± Overall wall motion
Easy to obtain ± liver is the acoustic
window\
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Subcostal ViewSubcostal View Most practical in
trauma setting
Away from airwayand neck/chestprocedures
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Subcostal ViewSubcostal View
Liver as acousticwindow
Alternative toapical 4 chamberview
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Subcostal ViewSubcostal View
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Subcostal ViewSubcostal View
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Subcostal ViewSubcostal View Angle probe right to
see IVC
Response of IVC tosniff indicates centralvenous pressure
No collapse
± Tamponade
± CHF
± PE
± Pneumothorax
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Parasternal ViewsParasternal Views Next best imaging window
Good for imaging LV
Comparing chamber sizes
Localized effusions
Differentiating pericardial from pleuraleffusions
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ParasternalLong AxisParasternalLong Axis
Near sternum
3rd or 4th left intercostal space
Marker pointed to patient¶s rightshoulder (or left hip if screen is notreversed for cardiac imaging)
Rotate enough to elongate cardiacchambers
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ParasternalLong AxisParasternalLong Axis
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Parasternal Long Axis ViewParasternal Long Axis View
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Parasternal Short AxisParasternal 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 differentcross sectional views
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Parasternal Short Axis ViewParasternal Short Axis View
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Parasternal Short AxisParasternal Short Axis
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Apical View Apical View Difficult view to obtain
Allows comparison of ventricular
chamber size
Good window to assess septal/wall
motion abnormalities
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Apical ViewsApical Views Patient in left
lateral decubitus
position Probe placed at
PMI
Probe marker at 6
o¶clock (or rightshoulder)
4 chamber view
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Apical 4 chamber viewApical 4 chamber view
Marker pointed tothe floor
Similar to
parasternal viewbut apex wellvisualized
Angle beamsuperiorly for 5chamber view
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Apical 4 chamber view Apical 4 chamber view
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Apical 2 chamber viewApical 2 chamber view Patient in left
lateral decubitus
position Probe placed at
PMI
Probe marker at 3o¶clock
2 chamber view
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Apical 2 chamber viewApical 2 chamber view Good look at inferior and anterior walls
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Apical 2 chamber viewApical 2 chamber view From apical 4,
rotate probe 90°
counterclockwise Good view for
long view of leftsided chambers
and mitral valve
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Abnormal findings Abnormal findings
Pericardial Effusion
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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 ³weeks´
Initial VS are BP 88/palp, HR 140
PE: Neck veins are distended Chest: Clear, muffled heart sounds
Bedside sonography was performed
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Echo free space around the heartEcho free space around the heart
Pericardial effusion
Pleural effusion
Epicardial fat (posterior and/oranterior)
Less common causes:
± Aortic aneurysm
± Pericardial cyst
± Dilated pulmonary artery
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Size of the PericardialSize of the Pericardial
EffusionEffusion Not Precise
Small: confined to posterior space,< 0.5cm
Moderate: anterior and posterior,0.5-2cm (diastole)
Large: > 2cm
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Pericardial Fluid: SubcostalPericardial Fluid: Subcostal
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Clinical features of Clinical features of
Pericardial effusionPericardial effusion Pericardial fluid accumulation may
be clinically silent
Symptoms are due to:
± mechanical compression of adjacentstructures
± Increased intrapericardial pressure
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PericardialPericardial
Effusion:AsymptomaticEffusion:Asymptomatic Up to 40% of pregnant women
Chronic hemodialysis patients± one study showed 11% incidence of pericardial effusion
AIDS
CHF
Hypoproteinemic states
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Symptoms of PericardialSymptoms of Pericardial
EffusionEffusion Chest discomfort (most common)
Large effusions:± Dyspnea± Cough
± Fatigue
± Hiccups± Hoarseness
± Nausea and abdominal fullness
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Ventricular collapse inVentricular collapse in
diastolediastole
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TamponadeTamponade
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HypotensionHypotension
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Abnormal findings Abnormal findings Is the cause of hypotension cardiac in
etiology? Is it due to a pericardial effusion?
Is is due to pump failure?
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Unexplained HypotensionUnexplained Hypotension Cardiogenic shock
± Poor LV contractility
Hypovolemia± Hyperdynamic ventricules
Right ventricular infarct/largepulmonary embolism
± Marked RV dilitation/hypokinesis Tamponade
± RV diastolic collapse
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Cardiogenic shockCardiogenic shock Dilated left
ventricle
Hypocontractilewalls
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HypovolemiaHypovolemia Small chamber filling size
Aggressive wall motion Flat IVC or exaggerated collapse
with deep inspiration
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Massive PE or RV infarctMassive PE or RV infarct Dilated Right
ventricle
RV hypokinesis Normal Left
ventricle function
Stiff IVC
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Case presentation ? overdoseCase presentation ? overdose 27 yo f brought in with ³passing out´
after night of heavy drinking.
Complaining of inability to breathe! PE: Obese f BP 88/60 HR 123 Ox
78%
Chest: clear Ext: No edema
Bedside sonography was performed
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Chest pain then codeChest pain then code
55 yo male suffered witnessed Vfib
arrest in the ED
ALS protocol - restoration of perfusing
rhythm
Persistant hypotension
ED ECHO was performed
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R sided leads
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Non TraumaticNon Traumatic
ResuscitationResuscitation
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Direct VisualizationDirect Visualization
Is there effective myocardialcontractility?
± Asystole± Myocardial ³twitch´
± Hypokinesis
± Normal
Is there a pericardial effusion?
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ECHO in PEAECHO in PEA
Perform ECHO during ³quick look´ and in pulse checks
Change management based on ³positive´ findings
Pericardial tamponade±
Pericardiocentesis Hyperdynamic cardiac wall motion
± Volume resuscitate
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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
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ECHO in PEAECHO in PEA
False positive cardiac motion
± Transthoracic pacemaker
± Positive pressure ventilation
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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
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Ineffective cardiacIneffective cardiac
contractionscontractions
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Optimizing PerformanceOptimizing Performance
Assessing capture by transthoracic
pacemaker
Pericardiocentesis
Transvenous pacemaker placement
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Optimizing PerformanceOptimizing Performance
Assessment of capture by transthoracic
pacemaker
Ettin D et al: Using ultrasound to
determine external pacer capture JEM 1999
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Case PresentationCase Presentation
70 yo f collapsed in lobby. She was broughtinto the ED apneic, hypotensive. She wasquickly 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. NoHSM, ? Pelvic mass
ECG: SB, LVH, no active ischemia
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Clinical questions?Clinical questions?
Why is she hypotensive?
Volume loss
?Ruptured AAA
Pump failure
Bedside sonography was performed
while we were waiting for the ³labs´
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Increase HR with PM ³on´Increase HR with PM ³on´
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What did this tell us?What did this tell us?
Normal wall motion
No pericardial/pleural effusion
Good capture with the transthoracic PM
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Asystole w/ Transthoracic PM Asystole w/ Transthoracic PM
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Optimizing performanceOptimizing performance
Pericardiocentesis
± Standard of care by cardiology/CT surgery
to use ECHO to guide aspiration
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US GuidedUS 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 tothe chest wall
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Large pericardial effusionLarge pericardial effusion
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TechniqueTechnique
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Optimizing performanceOptimizing performance
Placement of transvenous pacemaker
Aguilera P et al: Emergency
transvenous cardiac pacing placementusing ultrasound guidance. Ann Emerg
Med 2000
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Untimely endUntimely end
30 yo brought in after he ³fell out´
Ashen m with no spontaneous
respirations VS: No pulse, agonal rhythm on monitor
Intubated/CPR
Transvenous pacemaker placed, nocapture.
ECHO showed
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Penetrating Chest TraumaPenetrating Chest Trauma
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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
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Penetrating Cardiac InjuryPenetrating Cardiac Injury Emergency 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
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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
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Echocardiographic signs of risingintrapericardial 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 beforehypotension develops
Penetrating Cardiac TraumaPenetrating Cardiac Trauma
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Technical ProblemsTechnical Problems
Subcutaneous air
Pneumopericardium
Mechanical ventilation
Scanning limited by:
± Pain/tenderness
± Spinal immobilization
± Ongoing procedures
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Technical ProblemsTechnical Problems
Narrow intercostal spaces
Obesity
Muscular chest
COPD
Calcified rib cartilages
Abdominal distention
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Sonographic PitfallsSonographic Pitfalls Pericardial versus pleural fluid
Pericardial clot
Pericardial fat
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Pericardial or Pleural FluidPericardial or Pleural Fluid
Left 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 betweento RV free wall and the liver
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Pleural and Pericardial fluidPleural and Pericardial fluid
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Pleural effusionPleural effusion
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Blunt Cardiac TraumaBlunt Cardiac Trauma
Cardiac contusion
Cardiac rupture Valvular disruption
Aortic disruption/dissection
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Blunt Cardiac TraumaBlunt Cardiac Trauma
Pericardial effusion
Assess for wall motion abnormality
± RV dyskinesis (takes the first hit) Assess thoracic aorta:
± Hematoma
± Intimal flap
± Abnormal contour
Valvular dysfunction or septal rupture
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Cardiac ContusionCardiac Contusion
Akinetic anterior RV wall
Small pericardial effusion
Diminished ejection fraction
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RV ContusionRV Contusion
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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
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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