1. Emergency Cardiac Ultrasound: “Questions” Stephanie J. Doniger, MD FAAP

2. Emergency Cardiac US Focused questions: heart, pericardium Potentially life-threatening conditions Yes-No questions

3. Questions Is cardiac activity present? Global cardiac hyper/hypo -kinesis? Is there a pericardial effusion? Tamponade?

4. Abnormal Cardiac US Cardiac arrest, asystole Pericardial Fluid Hemopericardium Cardiac Tamponade

5. Cardiac Activity Sonographic 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

6. M-Mode

7. Wall Motion LV dysfunction Abnormal wall function Abnormal ventric emptying/relaxation Hypokinesia, akinesis, dyskinesia (paradoxic)

8. Hypokinesia

9. Pericardial Fluid Presence 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

10. Pericardial Effusions SmallModerateLarge Location Posterior Inferior to LV Extends to apex Circumscribes heart *Meas. @ Diastole <10 mm10-15 mm>15 mm *maximal width of pericardial stripe

11. Pericardial Effusion Subxiphoid

12. Pericardial Effusion PSSA

13. 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

14. 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

15. NOT Pericardial Effusions Pericardial fat pad Anterior Pleural effusions Intraabdominal fluid

16. Tamponade Compression 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

17. Tamponade: US Circumferential pericardial effusion “Scalloping” of RV Diastolic collapse of RV (or RA) Swinging heart CCW rotational movement Dilated IVC without inspiratory variation

18. Tamponade

20. Do you have questions?