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EmergencyCardiac Ultrasound:
“Questions”
Stephanie J. Doniger, MD FAAP
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Emergency Cardiac US
Focused questions: heart, pericardium
Potentially life-threatening conditions
Yes-No questions
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Questions
Is cardiac activity present?
Global cardiac hyper/hypo -kinesis?
Is there a pericardial effusion?
Tamponade?
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Abnormal Cardiac US
Cardiac arrest, asystole
Pericardial Fluid
Hemopericardium
Cardiac Tamponade
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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
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M-Mode
QuickTime™ and a decompressor
are needed to see this picture.
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Wall Motion
LV dysfunction
Abnormal wall function
Abnormal ventric emptying/relaxation
Hypokinesia, akinesis, dyskinesia (paradoxic)
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Hypokinesia
QuickTime™ and a decompressor
are needed to see this picture.
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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
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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
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Pericardial EffusionSubxiphoid
QuickTime™ and a decompressor
are needed to see this picture.
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Pericardial EffusionPSSA
QuickTime™ and a decompressor
are needed to see this picture.
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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
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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
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NOT Pericardial Effusions
Pericardial fat pad
Anterior
Pleural effusions
Intraabdominal fluid
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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
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Tamponade: US
Circumferential pericardial effusion
“Scalloping” of RV
Diastolic collapse of RV (or RA)
Swinging heart
CCW rotational movement
Dilated IVC without inspiratory variation
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Tamponade
QuickTime™ and a decompressor
are needed to see this picture.
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Tamponade
QuickTime™ and aMicrosoft Video 1 decompressorare needed to see this picture.
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Do you have questions?