Cardiology Ultrasound Emergency

8/8/2019 Cardiology Ultrasound Emergency

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Cardiac Ultrasound inCardiac Ultrasound in

Emergency MedicineEmergency Medicine

Anthony J. Weekes MD, RDMS

Sarah A. Stahmer MDFor the SAEM US Interest Group

Secondary IndicationsSecondary Indications

Acute Cardiac Ischemia

Pericardiocentesis

External pacer capture

Transvenous pacer placement

Main Clinical Questions

What is the overall cardiac wall motion?

Is there a pericardial effusion?

Cardiac probe selectionCardiac probe selection

Small round footprintfor scan between ribs

2.5 MHz: aboveaverage sized patient

3.5 MHz: averagesized patient

5.0 MHz: belowaverage sized patientor child

Main cardiac viewsMain cardiac views Parasternal

Subcostal

Apical

otionWallM

otion Normal

Hyperkinetic

Akinetic

Dyskinetic: may fail

to contract, bulges

outward at systole

Hypokinetic

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\

Subcostal ViewSubcostal View Most practical in

trauma setting

Away from airwayand neck/chestprocedures

Subcostal ViewSubcostal View

Liver as acousticwindow

Alternative toapical 4 chamberview

Subcostal ViewSubcostal View Angle probe right to

see IVC

Response of IVC tosniff indicates centralvenous pressure

No collapse

± Tamponade

± CHF

± Pneumothorax

Parasternal ViewsParasternal Views Next best imaging window

Good for imaging LV

Comparing chamber sizes

Localized effusions

Differentiating pericardial from pleuraleffusions

ParasternalLong AxisParasternalLong Axis

Near sternum

3rd or 4th left intercostal space

Marker pointed to patient¶s rightshoulder (or left hip if screen is notreversed for cardiac imaging)

Rotate enough to elongate cardiacchambers

ParasternalLong AxisParasternalLong Axis

Parasternal Long Axis ViewParasternal Long Axis View

Parasternal Short AxisParasternal 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 differentcross sectional views

Parasternal Short Axis ViewParasternal Short Axis View

Parasternal Short AxisParasternal Short Axis

Apical View Apical View Difficult view to obtain

Allows comparison of ventricular

chamber size

Good window to assess septal/wall

motion abnormalities

Apical ViewsApical Views Patient in left

lateral decubitus

position Probe placed at

Probe marker at 6

o¶clock (or rightshoulder)

4 chamber view

Apical 4 chamber viewApical 4 chamber view

Marker pointed tothe floor

Similar to

parasternal viewbut apex wellvisualized

Angle beamsuperiorly for 5chamber view

Apical 4 chamber view Apical 4 chamber view

Apical 2 chamber viewApical 2 chamber view Patient in left

lateral decubitus

position Probe placed at

Probe marker at 3o¶clock

2 chamber view

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

Apical 2 chamber viewApical 2 chamber view From apical 4,

rotate probe 90°

counterclockwise Good view for

long view of leftsided chambers

and mitral valve

Abnormal findings Abnormal findings

Pericardial Effusion

Case PresentationCase 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 ³weeks´

Initial VS are BP 88/palp, HR 140

PE: Neck veins are distended Chest: Clear, muffled heart sounds

Bedside sonography was performed

Echo free space around the heartEcho free space around the heart

Pericardial effusion

Pleural effusion

Epicardial fat (posterior and/oranterior)

Less common causes:

± Aortic aneurysm

± Pericardial cyst

± Dilated pulmonary artery

Size of the PericardialSize of the Pericardial

EffusionEffusion Not Precise

Small: confined to posterior space,< 0.5cm

Moderate: anterior and posterior,0.5-2cm (diastole)

Large: > 2cm

Pericardial Fluid: SubcostalPericardial Fluid: Subcostal

Clinical features of Clinical features of

Pericardial effusionPericardial effusion Pericardial fluid accumulation may

be clinically silent

Symptoms are due to:

± mechanical compression of adjacentstructures

± Increased intrapericardial pressure

PericardialPericardial

Effusion:AsymptomaticEffusion:Asymptomatic Up to 40% of pregnant women

Chronic hemodialysis patients± one study showed 11% incidence of pericardial effusion

Hypoproteinemic states

Symptoms of PericardialSymptoms of Pericardial

EffusionEffusion Chest discomfort (most common)

Large effusions:± Dyspnea± Cough

± Fatigue

± Hiccups± Hoarseness

± Nausea and abdominal fullness

Ventricular collapse inVentricular collapse in

diastolediastole

TamponadeTamponade

HypotensionHypotension

Abnormal findings Abnormal findings Is the cause of hypotension cardiac in

etiology? Is it due to a pericardial effusion?

Is is due to pump failure?

Unexplained HypotensionUnexplained Hypotension Cardiogenic shock

± Poor LV contractility

Hypovolemia± Hyperdynamic ventricules

Right ventricular infarct/largepulmonary embolism

± Marked RV dilitation/hypokinesis Tamponade

± RV diastolic collapse

Cardiogenic shockCardiogenic shock Dilated left

ventricle

Hypocontractilewalls

HypovolemiaHypovolemia Small chamber filling size

Aggressive wall motion Flat IVC or exaggerated collapse

with deep inspiration

Massive PE or RV infarctMassive PE or RV infarct Dilated Right

ventricle

RV hypokinesis Normal Left

ventricle function

Stiff IVC

Case presentation ? overdoseCase presentation ? overdose 27 yo f brought in with ³passing out´

after night of heavy drinking.

Complaining of inability to breathe! PE: Obese f BP 88/60 HR 123 Ox

Chest: clear Ext: No edema

Chest pain then codeChest 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

R sided leads

Non TraumaticNon Traumatic

ResuscitationResuscitation

Direct VisualizationDirect Visualization

Is there effective myocardialcontractility?

± Asystole± Myocardial ³twitch´

± Hypokinesis

± Normal

Is there a pericardial effusion?

ECHO in PEAECHO in PEA

Perform ECHO during ³quick look´ and in pulse checks

Change management based on ³positive´ findings

Pericardial tamponade±

Pericardiocentesis Hyperdynamic cardiac wall motion

± Volume resuscitate

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

False positive cardiac motion

± Transthoracic pacemaker

± Positive pressure ventilation

Case presentationCase 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

Ineffective cardiacIneffective cardiac

contractionscontractions

Optimizing PerformanceOptimizing Performance

Assessing capture by transthoracic

pacemaker

Pericardiocentesis

Transvenous pacemaker placement

Optimizing PerformanceOptimizing Performance

Assessment of capture by transthoracic

pacemaker

Ettin D et al: Using ultrasound to

determine external pacer capture JEM 1999

Case PresentationCase Presentation

70 yo f collapsed in lobby. She was broughtinto the ED apneic, hypotensive. She wasquickly 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. NoHSM, ? Pelvic mass

ECG: SB, LVH, no active ischemia

Clinical questions?Clinical questions?

Why is she hypotensive?

Volume loss

?Ruptured AAA

Pump failure

while we were waiting for the ³labs´

Increase HR with PM ³on´Increase HR with PM ³on´

What did this tell us?What did this tell us?

Normal wall motion

No pericardial/pleural effusion

Good capture with the transthoracic PM

Asystole w/ Transthoracic PM Asystole w/ Transthoracic PM

Optimizing performanceOptimizing performance

Pericardiocentesis

± Standard of care by cardiology/CT surgery

to use ECHO to guide aspiration

US GuidedUS Guided--

PericardiocentesisPericardiocentesis Subcostal approach

± Traditional approach

± Blind± Increased risk of injury to liver, heart

Echo guided

± Left parasternal preferred for needle entry

± Largest area of fluid collection adjacent tothe chest wall

Large pericardial effusionLarge pericardial effusion

TechniqueTechnique

Optimizing performanceOptimizing performance

Placement of transvenous pacemaker

Aguilera P et al: Emergency

transvenous cardiac pacing placementusing ultrasound guidance. Ann Emerg

Med 2000

Untimely endUntimely end

30 yo brought in after he ³fell out´

Ashen m with no spontaneous

respirations VS: No pulse, agonal rhythm on monitor

Intubated/CPR

Transvenous pacemaker placed, nocapture.

ECHO showed

Penetrating Chest TraumaPenetrating Chest Trauma

Penetrating Cardiac TraumaPenetrating 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

Penetrating Cardiac InjuryPenetrating 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

Penetrating Cardiac InjuryPenetrating 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

Echocardiographic signs of risingintrapericardial 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 beforehypotension develops

Penetrating Cardiac TraumaPenetrating Cardiac Trauma

Technical ProblemsTechnical Problems

Subcutaneous air

Pneumopericardium

Mechanical ventilation

Scanning limited by:

± Pain/tenderness

± Spinal immobilization

± Ongoing procedures

Technical ProblemsTechnical Problems

Narrow intercostal spaces

Obesity

Muscular chest

Calcified rib cartilages

Abdominal distention

Sonographic PitfallsSonographic Pitfalls Pericardial versus pleural fluid

Pericardial clot

Pericardial fat

Pericardial or Pleural FluidPericardial 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 betweento RV free wall and the liver

Pleural and Pericardial fluidPleural and Pericardial fluid

Pleural effusionPleural effusion

Blunt Cardiac TraumaBlunt Cardiac Trauma

Cardiac contusion

Cardiac rupture Valvular disruption

Aortic disruption/dissection

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

Cardiac ContusionCardiac Contusion

Akinetic anterior RV wall

Small pericardial effusion

Diminished ejection fraction

RV ContusionRV Contusion

Assess thoracic aorta

± Hematoma

± Intimal flap

± Abnormal contour

± Requires TEE and expertise!

Valvular dysfunction or septal rupture ± Requires expertise beyond our scope

SummarySummary

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

Cardiology Ultrasound Emergency

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