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Cardiac Ultrasound in Emergency Medicine Anthony J. Weekes MD, RDMS Sarah A. Stahmer MD For the SAEM US Interest Group.

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Presentation on theme: "Cardiac Ultrasound in Emergency Medicine Anthony J. Weekes MD, RDMS Sarah A. Stahmer MD For the SAEM US Interest Group."— Presentation transcript:

1 Cardiac Ultrasound in Emergency Medicine Anthony J. Weekes MD, RDMS Sarah A. Stahmer MD For the SAEM US Interest Group

2 Primary Indications Thoraco-abdominal trauma Pulseless Electrical Activity Unexplained hypotension Suspicion of pericardial effusion/tamponade

3 Secondary Indications Acute Cardiac Ischemia Pericardiocentesis External pacer capture Transvenous pacer placement

4 Main Clinical Questions What is the overall cardiac wall motion? Is there a pericardial effusion?

5 Cardiac 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

6 Main cardiac views Parasternal Subcostal Apical

7 Wall Motion Normal Hyperkinetic Akinetic Dyskinetic: may fail to contract, bulges outward at systole Hypokinetic

8 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\

9 Subcostal View Most practical in trauma setting Away from airway and neck/chest procedures

10 Subcostal View Liver as acoustic window Alternative to apical 4 chamber view

11 Subcostal View

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13 Angle probe right to see IVC Response of IVC to sniff indicates central venous pressure No collapse – Tamponade – CHF – PE – Pneumothorax

14 Parasternal Views Next best imaging window Good for imaging LV Comparing chamber sizes Localized effusions Differentiating pericardial from pleural effusions

15 Parasternal Long Axis Near sternum 3rd or 4th left intercostal space Marker pointed to patient’s right shoulder (or left hip if screen is not reversed for cardiac imaging) Rotate enough to elongate cardiac chambers

16 Parasternal Long Axis

17 Parasternal Long Axis View

18 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

19 Parasternal Short Axis View

20 Parasternal Short Axis

21 Apical View Difficult view to obtain Allows comparison of ventricular chamber size Good window to assess septal/wall motion abnormalities

22 Apical Views Patient in left lateral decubitus position Probe placed at PMI Probe marker at 6 o’clock (or right shoulder) 4 chamber view

23 Apical 4 chamber view Marker pointed to the floor Similar to parasternal view but apex well visualized Angle beam superiorly for 5 chamber view

24 Apical 4 chamber view

25 Apical 2 chamber view Patient in left lateral decubitus position Probe placed at PMI Probe marker at 3 o’clock 2 chamber view

26 Apical 2 chamber view Good look at inferior and anterior walls

27 Apical 2 chamber view From apical 4, rotate probe 90° counterclockwise Good view for long view of left sided chambers and mitral valve

28 Abnormal findings Pericardial Effusion

29 Case 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 140 PE: Neck veins are distended Chest: Clear, muffled heart sounds Bedside sonography was performed

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31 Echo free space around the heart Pericardial effusion Pleural effusion Epicardial fat (posterior and/or anterior) Less common causes: – Aortic aneurysm – Pericardial cyst – Dilated pulmonary artery

32 Size of the Pericardial Effusion Not Precise Small: confined to posterior space, < 0.5cm Moderate: anterior and posterior, 0.5-2cm (diastole) Large: > 2cm

33 Pericardial Fluid: Subcostal

34 Clinical features of Pericardial effusion Pericardial fluid accumulation may be clinically silent Symptoms are due to: – mechanical compression of adjacent structures – Increased intrapericardial pressure

35 Pericardial Effusion:Asymptomatic Up to 40% of pregnant women Chronic hemodialysis patients – one study showed 11% incidence of pericardial effusion AIDS CHF Hypoproteinemic states

36 Symptoms of Pericardial Effusion Chest discomfort (most common) Large effusions: – Dyspnea – Cough – Fatigue – Hiccups – Hoarseness – Nausea and abdominal fullness

37 Cardiac Tamponade Increased intracardiac pressures Limitation of ventricular diastolic filling Reduction of stroke volume and cardiac output

38 Ventricular collapse in diastole

39 Tamponade

40 Hypotension

41 Abnormal findings Is the cause of hypotension cardiac in etiology? Is it due to a pericardial effusion? Is is due to pump failure?

42 Unexplained Hypotension Cardiogenic shock – Poor LV contractility Hypovolemia – Hyperdynamic ventricules Right ventricular infarct/large pulmonary embolism – Marked RV dilitation/hypokinesis Tamponade – RV diastolic collapse

43 Cardiogenic shock Dilated left ventricle Hypocontractile walls

44 Hypovolemia Small chamber filling size Aggressive wall motion Flat IVC or exaggerated collapse with deep inspiration

45 Massive PE or RV infarct Dilated Right ventricle RV hypokinesis Normal Left ventricle function Stiff IVC

46 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 88/60HR 123 Ox 78% Chest: clear Ext: No edema Bedside sonography was performed

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49 Chest 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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52 R sided leads

53 Non Traumatic Resuscitation

54 Direct Visualization Is there effective myocardial contractility? – Asystole – Myocardial “twitch” – Hypokinesis – Normal Is there a pericardial effusion?

55 ECHO 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

56 ECHO 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

57 ECHO in PEA False positive cardiac motion – Transthoracic pacemaker – Positive pressure ventilation

58 Case 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

59 Ineffective cardiac contractions

60 Optimizing Performance Assessing capture by transthoracic pacemaker Pericardiocentesis Transvenous pacemaker placement

61 Optimizing Performance Assessment of capture by transthoracic pacemaker Ettin D et al: Using ultrasound to determine external pacer capture JEM 1999

62 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 80/50HR 50Afebrile 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

63 Clinical questions? Why is she hypotensive? Volume loss ?Ruptured AAA Pump failure Bedside sonography was performed while we were waiting for the “labs”

64 Increase HR with PM “on”

65 What did this tell us? Normal wall motion No pericardial/pleural effusion Good capture with the transthoracic PM

66 Asystole w/ Transthoracic PM

67 Optimizing performance Pericardiocentesis – Standard of care by cardiology/CT surgery to use ECHO to guide aspiration

68 US Guided- Pericardiocentesis 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

69 Large pericardial effusion

70 Technique

71 Optimizing performance Placement of transvenous pacemaker Aguilera P et al: Emergency transvenous cardiac pacing placement using ultrasound guidance. Ann Emerg Med 2000

72 Untimely end 30 yo brought in after he “fell out” Ashen m with no spontaneous respirations VS: No pulse, agonal rhythm on monitor Intubated/CPR Transvenous pacemaker placed, no capture. ECHO showed

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74 Penetrating Chest Trauma

75 Penetrating 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

76 Penetrating 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

77 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 Sensitivity 100%, specificity 96.9% PPV: 81% NPV:100% Time interval BUS to OR: 12.1 +/- 5.9 min

78 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 Trauma

79 Stab wound to the chest

80 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 Trauma

81 Technical Problems Subcutaneous air Pneumopericardium Mechanical ventilation Scanning limited by: – Pain/tenderness – Spinal immobilization – Ongoing procedures

82 Technical Problems Narrow intercostal spaces Obesity Muscular chest COPD Calcified rib cartilages Abdominal distention

83 Sonographic Pitfalls Sonographic Pitfalls Pericardial versus pleural fluid Pericardial clot Pericardial fat

84 Pericardial 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 between to RV free wall and the liver

85 Pleural and Pericardial fluid

86 Pleural effusion

87 Blunt Cardiac Trauma Cardiac contusion Cardiac rupture Valvular disruption Aortic disruption/dissection

88 Blunt 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

89 Cardiac Contusion Akinetic anterior RV wall Small pericardial effusion Diminished ejection fraction

90 RV Contusion

91 Blunt Cardiac Trauma Assess thoracic aorta – Hematoma – Intimal flap – Abnormal contour – Requires TEE and expertise! Valvular dysfunction or septal rupture – Requires expertise beyond our scope

92 Summary 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


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