Cardiac Ultrasound in Emergency Medicine Anthony J Weekes
- Slides: 92
Cardiac Ultrasound in Emergency Medicine Anthony J. Weekes MD, RDMS Sarah A. Stahmer MD For the SAEM US Interest Group
Primary Indications l Thoraco-abdominal l Pulseless Electrical Activity l Unexplained l Suspicion trauma hypotension of pericardial effusion/tamponade
Secondary Indications l Acute Cardiac Ischemia l Pericardiocentesis l External pacer capture l Transvenous pacer placement
Main Clinical Questions l What l Is is the overall cardiac wall motion? there a pericardial effusion?
Cardiac probe selection Small round footprint for scan between ribs l 2. 5 MHz: above average sized patient l 3. 5 MHz: average sized patient l 5. 0 MHz: below average sized patient or child l
Main cardiac views Parasternal l Subcostal l Apical l
Wall Motion l Normal l Hyperkinetic l Akinetic l Dyskinetic: may fail to contract, bulges outward at systole l Hypokinetic
Orientation l Subcostal or subxiphoid view l Best all around imaging window l Good for identification of: – Circumferential pericardial effusion – Overall wall motion l Easy to obtain – liver is the acoustic window
Subcostal View Most practical in trauma setting l Away from airway and neck/chest procedures l
Subcostal View Liver as acoustic window l Alternative to apical 4 chamber view l
Subcostal View
Subcostal View
Subcostal View Angle probe right to see IVC l Response of IVC to sniff indicates central venous pressure l No collapse l – Tamponade – CHF – PE – Pneumothorax
Parasternal Views l Next best imaging window l Good for imaging LV l Comparing chamber sizes l Localized effusions l Differentiating pericardial from pleural effusions
Parasternal Long Axis l Near sternum l 3 rd or 4 th left intercostal space l Marker pointed to patient’s right shoulder (or left hip if screen is not reversed for cardiac imaging) l Rotate enough to elongate cardiac chambers
Parasternal Long Axis
Parasternal Long Axis View
Parasternal Short Axis l Obtained by 90° clockwise rotation of the probe towards the left shoulder (or right hip) l Sweep the beam from the base of the heart to the apex for different cross sectional views
Parasternal Short Axis View
Parasternal Short Axis
Apical View l Difficult view to obtain l Allows comparison of ventricular chamber size l Good window to assess septal/wall motion abnormalities
Apical Views Patient in left lateral decubitus position l Probe placed at PMI l Probe marker at 6 o’clock (or right shoulder) l 4 chamber view l
Apical 4 chamber view Marker pointed to the floor l Similar to parasternal view but apex well visualized l Angle beam superiorly for 5 chamber view l
Apical 4 chamber view
Apical 2 chamber view Patient in left lateral decubitus position l Probe placed at PMI l Probe marker at 3 o’clock l 2 chamber view l
Apical 2 chamber view l Good look at inferior and anterior walls
Apical 2 chamber view From apical 4, rotate probe 90° counterclockwise l Good view for long view of left sided chambers and mitral valve l
Abnormal findings Pericardial Effusion
Case Presentation l 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” l Initial VS are BP 88/palp, HR 140 l PE: Neck veins are distended l Chest: Clear, muffled heart sounds l Bedside sonography was performed
Echo free space around the heart l Pericardial effusion l Pleural effusion l Epicardial fat (posterior and/or anterior) l Less common causes: – Aortic aneurysm – Pericardial cyst – Dilated pulmonary artery
Size of the Pericardial Effusion l Not Precise l Small: confined to posterior space, < 0. 5 cm l Moderate: anterior and posterior, 0. 52 cm (diastole) l Large: > 2 cm
Pericardial Fluid: Subcostal
Clinical features of Pericardial effusion l Pericardial fluid accumulation may be clinically silent l Symptoms are due to: – mechanical compression of adjacent structures – Increased intrapericardial pressure
Pericardial Effusion: Asymptomatic l Up to 40% of pregnant women l Chronic hemodialysis patients – one study showed 11% incidence of pericardial effusion l AIDS l CHF l Hypoproteinemic states
Symptoms of Pericardial Effusion l Chest discomfort (most common) l Large effusions: – – – Dyspnea Cough Fatigue Hiccups Hoarseness Nausea and abdominal fullness
Cardiac Tamponade l Increased intracardiac pressures l Limitation of ventricular diastolic filling l Reduction of stroke volume and cardiac output
Ventricular collapse in diastole
Tamponade
Hypotension
Abnormal findings l Is the cause of hypotension cardiac in etiology? l Is it due to a pericardial effusion? l Is is due to pump failure?
Unexplained Hypotension l Cardiogenic shock – Poor LV contractility l Hypovolemia – Hyperdynamic ventricules l Right ventricular infarct/large pulmonary embolism – Marked RV dilitation/hypokinesis l Tamponade – RV diastolic collapse
Cardiogenic shock l Dilated left ventricle l Hypocontractile walls
Hypovolemia l Small chamber filling size l Aggressive l Flat wall motion IVC or exaggerated collapse with deep inspiration
Massive PE or RV infarct Dilated Right ventricle l RV hypokinesis l Normal Left ventricle function l Stiff IVC l
Case presentation ? overdose l 27 yo f brought in with “passing out” after night of heavy drinking. l Complaining of inability to breathe! l PE: Obese f BP 88/60 HR 123 Ox 78% l Chest: clear l Ext: No edema l Bedside sonography was performed
Chest pain then code l 55 yo male suffered witnessed Vfib arrest in the ED l ALS protocol - restoration of perfusing rhythm l Persistant hypotension l ED ECHO was performed
R sided leads
Non Traumatic Resuscitation
Direct Visualization l Is there effective myocardial contractility? – Asystole – Myocardial “twitch” – Hypokinesis – Normal l Is there a pericardial effusion?
ECHO in PEA l Perform ECHO during “quick look” and in pulse checks l Change management based on “positive” findings l Pericardial tamponade – Pericardiocentesis l Hyperdynamic cardiac – Volume resuscitate wall motion
ECHO in PEA l RV dilatation – Hypoxic? ? – Likely PE – ECG – IMI with RV infarct? l Profound hypokinesis – Inotropic support l Asystole – Follow ACLS protocols (for now) – Early data suggesting poor prognosis
ECHO in PEA l False positive cardiac motion – Transthoracic pacemaker – Positive pressure ventilation
Case presentation l l l l 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
Ineffective cardiac contractions
Optimizing Performance l Assessing capture by transthoracic pacemaker l Pericardiocentesis l Transvenous pacemaker placement
Optimizing Performance l Assessment of capture by transthoracic pacemaker l Ettin D et al: Using ultrasound to determine external pacer capture JEM 1999
Case 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
Clinical questions? l Why is she hypotensive? l Volume loss ? Ruptured AAA l Pump failure l Bedside sonography was performed while we were waiting for the “labs”
Increase HR with PM “on”
What did this tell us? l Normal l No wall motion pericardial/pleural effusion l Good capture with the transthoracic PM
Asystole w/ Transthoracic PM
Optimizing performance l Pericardiocentesis – Standard of care by cardiology/CT surgery to use ECHO to guide aspiration
US Guided. Pericardiocentesis l Subcostal approach – Traditional approach – Blind – Increased risk of injury to liver, heart l Echo guided – Left parasternal preferred for needle entry or… – Largest area of fluid collection adjacent to the chest wall
Large pericardial effusion
Technique
Optimizing performance l Placement of transvenous pacemaker l Aguilera P et al: Emergency transvenous cardiac pacing placement using ultrasound guidance. Ann Emerg Med 2000
Untimely end l 30 yo brought in after he “fell out” l Ashen m with no spontaneous respirations l VS: No pulse, agonal rhythm on monitor l Intubated/CPR l Transvenous pacemaker placed, no capture. l ECHO showed
Penetrating Chest Trauma
Penetrating Cardiac Trauma Physician’s ability to determine whethere is a hemodynamically significant effusion is poor l Beck’s Triad l – Dependent on patient cardiovascular status – Findings are often late l Determinants of hemodynamic compromise – Size of the effusion – Rate of formation
Penetrating Cardiac Injury l 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 l Survival: 100% in echo, 57. 1% in nonecho l Time to Dx: 15 min echo, 42 min nonecho l
Penetrating 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 l Sensitivity 100%, specificity 96. 9% l PPV: 81% NPV: 100% l Time interval BUS to OR: 12. 1 +/- 5. 9 min l
Penetrating Cardiac Trauma 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 twodimensional echocardiography, the time to diagnosis of penetrating cardiac injury has decreased and both the survival rate and neurologic outcome of survivors has improved. ”
Stab wound to the chest
Penetrating Cardiac Trauma l Echocardiographic signs of rising intrapericardial pressure – Collapse of RV free walls – Dilated IVC and hepatic veins l Goal: Early detection of pericardial effusion – Develops suddenly or discretely – May exist before clinical signs develop l Salvage rates better if detected before hypotension develops
Technical Problems l Subcutaneous air l Pneumopericardium l Mechanical ventilation l Scanning limited by: – Pain/tenderness – Spinal immobilization – Ongoing procedures
Technical Problems l Narrow intercostal spaces l Obesity l Muscular chest l COPD l Calcified rib cartilages l Abdominal distention
Sonographic Pitfalls l Pericardial versus pleural fluid l Pericardial clot l Pericardial fat
Pericardial or Pleural Fluid l Left parasternal long axis: – Pericardial fluid does not extend posterior to descending aorta or left atrium l Subcostal: – No pleural reflection between liver and R sided chambers – A pleural effusion will not extend between to RV free wall and the liver
Pleural and Pericardial fluid
Pleural effusion
Blunt Cardiac Trauma l Cardiac contusion l Cardiac rupture l Valvular disruption l Aortic disruption/dissection
Blunt Cardiac Trauma l Pericardial effusion l Assess for wall motion abnormality – RV dyskinesis (takes the first hit) l Assess thoracic aorta: – Hematoma – Intimal flap – Abnormal contour l Valvular dysfunction or septal rupture
Cardiac Contusion l Akinetic l Small anterior RV wall pericardial effusion l Diminished ejection fraction
RV Contusion
Blunt Cardiac Trauma l Assess thoracic aorta – Hematoma – Intimal flap – Abnormal contour – Requires TEE and expertise! l Valvular dysfunction or septal rupture – Requires expertise beyond our scope
Summary l Bedside ECHO can help assess: – Overall cardiac wall motion – Identify clinically significant pericardial effusions l Useful in the assessment of the patient with: – Unexplained hypotension – Dyspnea – Thoracic trauma
- Pcos ultrasound image
- Lauren weekes
- Tony weekes
- Trevor weekes
- University of arizona emergency medicine
- Emergency medicine case presentation
- Dutch north sea emergency medicine conference
- Unm internal medicine residents
- Cmc vellore handbook of emergency medicine
- Resistive index doppler
- Piezoelectric effect ultrasound
- Beam focusing in ultrasound
- Coupon para epiduo
- Antenatal investigations
- Beam ultrasound
- Rush ultrasound protocol
- Ultrasound trch salary
- Dynamic frequency tuning ultrasound
- Hifu
- Ecg gel composition
- Ultrasound beam attenuation
- Dr barekatain
- Ultrasound awareness month
- Yolk sac ultrasound
- Cerebral peduncle ultrasound
- Rtesticle
- Ultrasound scanner
- Ekos ultrasound
- Duplex doppler ultrasound
- How does ultrasound work
- Pelvic ultrasound
- Intravascular ultrasound
- Ultrasound time gain compensation
- Causes of decreased fetal movement
- Intraluminal intramural extramural
- Warthin's tumor ultrasound images
- Walden ultrasound
- Neurocritical care society
- Valves of heister ultrasound
- 8 weeks pregnant ultrasound
- Spalding sign
- Cbd ultrasound
- Anti radial vs radial ultrasound
- Cvs personal lubricant
- Blood gas
- True labour pain definition
- Ultrasound
- Hypoechoic ultrasound
- Ultrasound wavelength
- Ultrasound guidelines council
- "rbs"
- Ultrasound guidelines council
- Ultrasound report format word
- Near zone length ultrasound
- Profile
- Down syndrome baby ultrasound picture
- Ivus
- Ultrasound
- Montecarlo
- Ultrasound image optimisation
- Sound travels fastest in
- Some bat caves like honeybee hives
- Feminax ultra asda
- Cus (compression ultrasonography)
- Abnormal fetal brain ultrasound
- L
- Dfmcr in pregnancy
- Cbd ultrasound
- Self breast exam
- Endometrium
- Caponography
- Pcos ultrasound report
- Head ultrasound
- Era ultrasound
- Sdt ultrasound solutions
- Ultrasound imaging
- Osgood schlatter radiopaedia
- Hepatomegaly ultrasound
- Fetal brain anatomy ultrasound
- Pelvic ultrasound
- Display modes in ultrasound
- Ergonomics medical definition
- Neurointerventional ultrasound
- Breast ultrasound
- Exago ultrasound price
- Difference between doppler and duplex
- Fast ultrasound
- Siemens ultrasound roadshow
- Smooth muscle under the microscope
- Cardiac cycle
- Eccentric movement
- Cpmc cardiac rehab
- Dobutamine vs dopamine