1. Focused Echocardiographic Examination in the Emergency Room and Critical Care Units
Ronald E. Cuyco, MD, FPCC

2. Emergency Echocardiography
Advantages of echocardiography as a diagnostic tool in the emergency room and in the ICU:
Safe and tolerable
Easily reproducible
Readily available (portability)
Relatively low-cost
No radiation

3. Emergency Echocardiography
What emergency situations should be assessed?
Acute chest pains
Acute dyspnea
Hemodynamic instability (hypotension/shock)
New murmur
Chest trauma
Cardiac sources of embolism
Cardiac arrest/CPR
ESC Congress 2011

4. Emergency Echocardiography
Where can emergency echocardiography be performed?
Emergency room
CCU –Coronary Care Unit
ICU/cardiac ICU – Intensive Care Unit
Operating room
Cardiac catheterization laboratory
Bedside
Ambulance (hand-held echocardiography)
Outside of the hospital
ESC Congress 2011

5. Emergency Echocardiography
Philippine Heart Center Echocardiograpy Census (2011)
Total In-patient Echo ,407
Bedside Echo (ER and ICU) 1,110 (25%)
Intra-operative TEE (IOTEE) ( 5%)
Top 3 indications for emergency echocardiography:
Chest pains
Dyspnea
Hypotension

6. Emergency Echocardiography
Acute chest pains and dyspnea
Acute myocardial ischemia or infarction
Aortic dissection
Pulmonary embolism

7. Emergency Echocardiography: Aortic Dissection
TTE findings associated with aortic dissection
Aortic insufficiency
Enlarged aortic root (>3.5 cm at annulus or sino-tubular junction)
Presence of pericardial effusion
Infero-posterior wall motion abnormality (RCA territory)

8. Emergency Echocardiography
Aortic Dissection
May require TEE to visualize distal ascending aorta, transverse and descending aorta
Intimal flap seen on TTE would clinch a diagnosis of aortic dissection
Lack of definite signs on TTE/TEE does not exclude an aortic dissection, CLINICAL DATA still important

9. Echo: Aortic dissection
Suprasternal view of aorta showing the intimal flap
Color flow doppler within the false and true lumen

10. Cardiac CT-MRI: Aortic Dissection
Complimentary tools to emergency echocardiography to rule-in or rule-out aortic dissection
Cardiovascular CT-MRI “triple rule-out” capability is an advantage over other modalities
Disadvantages: not readily available, non-portable, expensive, and requires highly skilled technician and staff

11. Emergency Echocardiography: Acute Coronary Syndrome
Wall thickening abnormalities
Evidence of ruptured interventricular septum, LV free wall or papillary muscle
LV systolic and diastolic functions
Cardiac filling pressures
Pulmonary pressure

12. Acute myocardial infarction with Ruptured Ventricular Septum
4-chamber view showing the echo drop-out space across the IV septum
Color flow doppler demonstrating mosaic flow across the septal defect

13. LV systolic function LV systolic function is not just EF!
Fractional shortening
Stroke volume
Cardiac index
Systolic tissue velocity of the mitral annulus and myocardium
Strain
Regional wall motion
LV systolic function is a reflection of the pumping action of the heart
Echocardiography can measure several parameters as an expression of the systolic function of the heart. These parameters are…

14. Stroke volume

15. Simpson’s rule

16. M-Mode
Standard M-mode assesment use leading edge to edge convention following the most continous echo line to come up with dimensions and volumes. To obtain accurate linear measurements of IVS wall thickness, post wall thickness and LV internal dimension, recording should be made from a parasternal long-axis window. It is recommended that LV int dimensions and wall thickness be measured at the level of the LV minor axis, approximately at the level of the MV leaflet tips.
Recommendations for Chamber Quantification: A Report from the American Society of Echocardiography Guidelines and Standards Committee and the Chamber Quantification Writing Group, Developed in Conjunction with the European Association of Echocardiography, a Branch of the European Society of Cardiology

17. Systolic tissue Doppler velocity in normal and abnormal
Normal Sm = 12 cm/sec
Abnormal Sm = 6 cm/sec
DTI

18. Khouri et al, JASE, March 2004

19. Doppler Tissue Imaging (DTI)
E/Ea ratio – correlates well with LV filling pressure
E/Ea ratio > 15
Highly specific for elevated LA pressure
E/Ea < 8
Sensitive for normal LA pressure
Khouri et al, JASE March 2004
E/Ea ratio < 10
- PCWP < 15 mmHg
- PCWP > 20 mmHg
Nagueh et al. Circulation. 2000

20. Doppler Assessment of LV filling pressures in patients with AF
Method
Cut-off
Accuracy
E wave Deceleration time
< 120 ms
Sens/Spec 100%/96% in predicting PAOP > 20 mmHg
Isovolumic relaxation time
< 65 ms
Sens/Spec 72%/82% in predicting PAOP of > 15 mmHg
E/Ea ratio
> 11
Sens/Spec 75%/93% in predicting PAOP of >15 mmHg
E/Vp
> 1.4
Sens/Spec 72%/100% in predicting a PAOP of > 15 mmHg
Hemodynamic monitoring using Echo, De Backer, 2011

21. Measurement of pulmonary artery pressure

22. Pulmonary Hypertension

23. Emergency Echocardiography: RV systolic overload
Elevated right ventricular afterload leading to pulmonary hypertension and right heart failure
Echocardiographic features:
Dilated pulmonary artery, right ventricle and right atrium
Hypokinetic right ventricle
Moderate to severe TR with elevated pulmonary systolic arterial pressure
Systolic septal flattening
No significant left heart abnormality

24. Pulmonary artery mass
Parasternal short-axis view at the AV level showing the mobile echogenic density within the pulmonary artery
Apical 4-chamber view

25. RVEF by 3D Echocardiography
Full-volume reconstruction of the right ventricle with EF computation

26. ER Echocardiography: Chest Trauma
Echocardiographic findings to look for:
Rupture of cardiac structures (valves and myocardium)
Myocardial contusion (RWMA of the anterior right-sided structures)
Pericardial effusion
Aortic rupture or intimal tear (TEE maybe useful if not contraindicated)
Ruptured coronary sinus of Valsalva

27. Traumatic RCSOV Ruptured coronary sinus of valsalva due to stabbing
TEE with color flow doppler demonstrating the mosaic color flow across the rupture site

28. Assessment of volume status and responsiveness to fluid challenge
Hypotensive or patients in circulatory shock due to hypovelemia or sepsis
IVC diameter could be a good estimate of CVP
SVC and IVC diameter changes in ventilated patients can predict patients’ fluid responsiveness
Respiratory changes in aortic blood flow VTI separate responders from non-responder patients to fluid challenge

29. Assessment of volume status
CVP can be estimated by the size of IVC
INSPIRAT
EXPIRATI
IVC is virtually collapsed during inspiration
Hemodynamic monitoring using Echo, De Backer, 2011

30. IVC diameter changes during mechanical ventilation
ins
exp
Collapsibility index can be calculated by measuring the largest and smallest diameters
Hemodynamic monitoring using Echo, De Backer, 2011

31. SVC collapsibility in ventilated patients
No change during mechanical insufflation
Large diameter changes during mechanical insufflation indicate a responder patient to fluid challenge
Hemodynamic monitoring using Echo, De Backer, 2011

32. Response to fluid challenge: Stroke volume monitoring
500 ml infused
SV 65 ml
Hemodynamic monitoring using Echo, De Backer, 2011
SV 38 ml

33. Cardiac volume and filling pressures
70 ml
65 ml
38 ml
Restriction to filling
Normalized profile
Abnormal relaxation
Hemodynamic monitoring using Echo, De Backer, 2011

34. Emergency Echocardiography
Transthoracic or Transesophageal Echocardiography ?
TTE should be the first-line diagnotic procedure over TEE due to its versatility, availability and tolerance.
TEE is the procedure of choice in the assessment of circulatory failure complicating peri-operative course.
TEE is needed when TTE image quality is inadequate as in ventilated patients, COPD and obese patients.

35. Myocardial Contrast Echocardiography in the ER and ICU settings

36. 3D echo for LV analysis
Left ventricular volumes calculated with a tracing algorithm obtained using 2 planes (4-and 2-chamber views). This shortens processing time
Full-volume reconstruction of the LV with EF computation

37. Summary
Echocardiographic examination in the emergency room can facilitate prompt diagnosis of aortic pathology, pulmonary embolism, myocardial ischemia or infarction and its complication, as well as unexplained hypotension.
Echocardiography remains an important diagnostic tool in the evaluation of patients with circulatory or respiratory failure in critical care setting.

38. In ICU setting, echocardiography plays an essential role in ensuring prompt and correct diagnosis, as well as in hemodynamic monitoring.
Application of new technological advances like myocardial contrast echocardiography, tissue Doppler imaging and 3D echocardiography improves the capabilities of echocardiography in emergency and critical care settings.

39. Thank you

40. RV systolic function assessment
Visual inspection of RV free-wall motion and tricuspid annulus motion
TAPSE
Tissue Doppler imaging
RV fractional area change
RV ejection fraction by 3D echo

41. Aortic blood flow respiratory variation
INSPIRATION
EXPIRATION
Large respiratory change indicates positive response to fluid infusion
Hemodynamic monitoring using Echo, De Backer, 2011

42. Emergency Echocardiography
Unexplained hypotension, syncope and arrhythmia
Pericardial effusion with tamponade
Hypovolemia/ sepsis
Segmental or global hypokinesia with depressed systolic function
Aortic stenosis
Hypertrophic obstructive cardiomyopathy

43. Assessment of LV filling pressure
Color M-mode Vp
Tissue Doppler (Ea)

44. Massive pericardial effusion
Parasternal short-axis view at the mid-LV level showing the pericardial effusion
Apical 4-chamber view showing the pericardial effusion

45. 3D Echocardiography in the Emergency Room
Accurate and reproducible ventricular function assessment (LV and RV) – volume and ejection fraction
Assessment of valvular pathology

46. RAP as estimated by IVC size
RAP (mmHg)
IVC size (cm)
IVC contraction
(inspiration %)
Hepatic vein
0 – 5
< 20
> 50
Normal 10
< 50 15
> 20 20
Dilated

47. Measurement of Pulmonary Arterial Pressure
PASP = 4 X (TR jet velocity)2 + RAP PAEDP = 4 X (PR jet end-diastolic velocity)2 +RAP Mean PAP = 4 X (PR jet peak velocity)2 or 80 – RVOT AT/2

48. Responsiveness to Fluid Challenge
Parameters to monitor:
IVC diameter change on ventilator insufflation (TTE)
SVC diameter change on ventilator insufflation (TEE)
Aortic blood flow respiratory variation

49. dP/dt using MR jet
An additional parameters of left ventricular global function is the calculation of left ventricular dP/dt. This represents the rate of increase in pressure within the left ventricle. Using the spectral display of a mitral regurgitation jet, it is possible to derive information re the rate of pressure devt within the LV. If this measurement is undertaken in the early phases of systole while the increasing ventricular pressure is less than the aortic pressure, it is relatively load independent. The method by which this is performed is to record the mitral regurgitation spectral profile at a high sweep speed (typically 100 mm/sec), Examination of the early velocity curve can thenbe used to derive instantaneous pressure measurements. To determine the dP/dt, one calculates the time difference in milliseconds from the point at which the velocity is at 1 m/sec and at 3 m/sec.
The time between these two points represents the time that it takes for a 32 mm Hg change to occur in the left ventricular cavity. dP/dt is then calculated as: dP/dt = 32 mm Hg ﾃｷ time (seconds). Determination of dP/dt using this method has been validated against invasive hemodynamic measurements. Either a reduced positive or negative dP/dt carries significant prognostic implications. There are contributors to left ventricular dP/dt in addition to intrinsic myocardial contractility. In the presence of marked mechanical dysynchrony (as typified by left bundle branch block), dP/dt may be reduced, not due to decreased contractility but rather as a consequence of contractile dysynchrony and pump inefficiency.

50. Left Ventricular Volume (M-mode)
Stroke volume (SV) = LVEDV – LVESV
Cardiac Output (CO) = SV x HR
1000
Cardiac Index (CI) = C O
BSA
Where: LVEDV= end diastolic volume
LVESV= end systolic volume
HR = heart rate
1000 = conversion of cc to liters
BSA = body surface area
Stroke volume – amount of blood pumped by
the heart on each heartbeat
Cardiac output – volume of blood pumped by
the heart per minute
Both can be calculated using LVED and LVES volumes derived from M-mode
Left ventricular volume calculation are based on the assumption that the left ventricle is shaped like a prolate ellipse

51. Doppler Evaluation of LV Systolic Function
Basically the principle is that if the CSA of flow is known, then the product of the CSA and the mean velocity of flow equals volumetric flow.

52. Critical Care Echocardiography
Echocardiography is best suited for the evaluation of unstable patients in the ICU due to its versatility, safety and capability of providing instantaneous diagnosis
Echocardiography is especially requested for the assessment of circulatory failure and shock

53. Critical Care Echocardiography: Indications
Circulatory failure (hypotension and shock)
eg. Complicated MI, pulmonary embolism, cardiac tamponade
Cardiac arrest (during or after successful resuscitation)
Respiratory failure
eg. Cardiogenic pulmonary edema vs ARDS
Other clinical settings like chest trauma, infective endocarditis and cardioembolic phenomena

54. Focused Echocardiography in Critical Care
Basic ventricular dysfunction assessment (RV and LV)
Volume status assessment and response to fluid challenge
Assessment of cardiac filling pressures
Measurement of cardiac output and pulmonary artery pressure
Assessment of valve pathology and pericardial tamponade
Echocardiographic evaluation in life support

55. Emergency Echocardiography
Accurate management of chest pains in the emergency room requires knowledge of the differential diagnosis and an appropriate use of diagnostic tools.

56. Emergency Echocardiography: Acute Chest Pains

57. Other causes of regional wall motion abnormality aside from acute myocardial ischemia:
Prior myocardial infarction
Focal myocarditis
Prior surgery
Right ventricular overload
Left bundle branch block
WPW-ventricular pre-excitation
Cardiomyopathy
Paced rhythm

58. Emergency Echocardiography
Focused peri-resuscitation and critical echocardiography pp33 and 35 ESC guideline

59. Myocardial Contrast Echocardiography