echo

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

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

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

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

5. Cardiac probe selectionCardiac 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 viewsMain cardiac views
 Parasternal
 Subcostal
 Apical

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

8. OrientationOrientation
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 ViewSubcostal View
 Most practical in
trauma setting
 Away from airway
and neck/chest
procedures

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

11. Subcostal ViewSubcostal View

12. Subcostal ViewSubcostal View

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

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

15. Parasternal Long AxisParasternal 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 AxisParasternal Long Axis

17. Parasternal Long Axis ViewParasternal Long Axis View

18. 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 different
cross sectional views

19. Parasternal Short Axis ViewParasternal Short Axis View

20. Parasternal Short AxisParasternal Short Axis

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

22. Apical ViewsApical 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 viewApical 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 viewApical 4 chamber view

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

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

28. Abnormal findingsAbnormal findings
Pericardial Effusion

29. 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 “weeks”
Initial VS are BP 88/palp, HR 140
PE: Neck veins are distended
Chest: Clear, muffled heart sounds
Bedside sonography was performed

31. Echo free space around the heartEcho 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 PericardialSize of the Pericardial
EffusionEffusion
Not Precise
Small: confined to posterior space,
< 0.5cm
Moderate: anterior and posterior,
0.5-2cm (diastole)
Large: > 2cm

33. Pericardial Fluid: SubcostalPericardial Fluid: Subcostal

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

35. PericardialPericardial
Effusion:AsymptomaticEffusion: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 PericardialSymptoms of Pericardial
EffusionEffusion
Chest discomfort (most common)
Large effusions:
– Dyspnea
– Cough
– Fatigue
– Hiccups
– Hoarseness
– Nausea and abdominal fullness

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

38. Ventricular collapse inVentricular collapse in
diastolediastole

39. TamponadeTamponade

40. HypotensionHypotension

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

42. Unexplained HypotensionUnexplained 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 shockCardiogenic shock
 Dilated left
ventricle
 Hypocontractile
walls

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

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

46. Case presentation ? overdoseCase presentation ? overdose
27 yo f brought in with “passing out”
after night of heavy drinking.
Complaining of inability to breathe!
PE: Obese f BP 88/60 HR 123 Ox
78%
Chest: clear
Ext: No edema
Bedside sonography was performed

49. 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

52. R sided leads

53. Non TraumaticNon Traumatic
ResuscitationResuscitation

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

55. ECHO in PEAECHO 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 PEAECHO 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 PEAECHO in PEA
False positive cardiac motion
– Transthoracic pacemaker
– Positive pressure ventilation

58. 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

59. Ineffective cardiacIneffective cardiac
contractionscontractions

60. Optimizing PerformanceOptimizing Performance
Assessing capture by transthoracic
pacemaker
Pericardiocentesis
Transvenous pacemaker placement

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

62. Case PresentationCase 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

63. Clinical questions?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”Increase HR with PM “on”

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

66. Asystole w/ Transthoracic PMAsystole w/ Transthoracic PM

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

68. US Guided-US Guided-
PericardiocentesisPericardiocentesis
 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 effusionLarge pericardial effusion

70. TechniqueTechnique

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

72. Untimely endUntimely 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

74. Penetrating Chest TraumaPenetrating Chest Trauma

75. 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

76. 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

77. 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

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 TraumaPenetrating Cardiac Trauma

79. Stab wound to the chestStab 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 TraumaPenetrating Cardiac Trauma

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

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

83. Sonographic PitfallsSonographic Pitfalls
Pericardial versus pleural fluid
Pericardial clot
Pericardial fat

84. 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 between
to RV free wall and the liver

85. Pleural and Pericardial fluidPleural and Pericardial fluid

86. Pleural effusionPleural effusion

87. Blunt Cardiac TraumaBlunt Cardiac Trauma
Cardiac contusion
Cardiac rupture
Valvular disruption
Aortic disruption/dissection

88. Blunt Cardiac TraumaBlunt 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 ContusionCardiac Contusion
Akinetic anterior RV wall
Small pericardial effusion
Diminished ejection fraction

90. RV ContusionRV Contusion

91. Blunt Cardiac TraumaBlunt 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. 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