This document discusses the use of echocardiography in emergency clinical situations. It provides examples of common clinical indications for emergency echocardiography including hemodynamic instability, aortic dissection, acute coronary syndromes, and critically ill patients. The document outlines echocardiography algorithms and describes how to use echocardiography to diagnose conditions like cardiac tamponade, pulmonary embolism, hypotension, and penetrating chest trauma. Key findings are highlighted for various emergency scenarios.

1. Dr.
Ayman Abdelaziz
Assisstant Prof. of Cardiology
Mansoura University
ECHOCARDIOGRAPHY IN
EMERGENCY

2. CLINICAL INDICATION
• 1- Hemodynamic instability and/or hypoxemia of unclear aetiolog
(i) Suspected tamponade
(ii) Pulseless electrical activity (PEA) can be the presenting symptom for:
• Tamponade • Massive pulmonary embolism
• Acute massive internal hemorrhage • Tension pneumothorax
• 2- Aortic dissection 3- Acute coronary syndromes
• 4- Acute valvular pathology, Prosthetic valve malfunction
• 5- Infective endocarditis 6- Massive Pulmonary embolism
• 7- Acute embolic event
• 8- Critically ill patients due to non-cardiac illness: cardiac function and left
ventricular (LV) filling may be crucial to guide fluid resuscitation:
• (a) septic shock and (b) diabetic ketoacidosis.

3. ECHO ALGORITHM
Unstable patient with shock or pulmonary oedema
Quick targeted Echo (minimum views subcostal ,
Apical)
moderate
pericardial effusion
 Compressed
RA/RV
Collapsed IVC
Severely
enlarged akinetic
RV
Severe
hypokinetic LV
Small hyperdynamic
heart
 Collapsed IVC
Assume
tamponade
Assume
pulmonary
embolism
Assume
acute pump
failure MI
Myocarditis)
Assume severe
hypovolemia
Major internal
bleeding
Sepsis

4. PERICARDIAL TAMPONADE

6. EUROECHO CONGRESS - COPENHAGEN -
TEACHING COURSE 2010
RV and RA collapse
• Without these
collapses
cardiac
tamponade is
unlikely

7. DIAGNOSIS
• Echocardiogram (tamponade is clinical diagnosis)
• Pericardial effusion
• Early diastolic collapse of the right ventricular free wall
• Late diastolic compression/collapse of the right atrium
• Swinging of the heart in its sac
• Respiratory variation of mitral and tricuspid flow
• Dilated IVC (collapse < 50%)

13. RESPIRATORY VARIATION OF THE MITRAL FLOW

14. ECHO 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

15. PULMONARY EMBOLISM

16. ECHOCARDIOGRAPHY IN PE: TO
IDENTIFY RV OVERLOAD
• RV dilatation.
• Abnormal right ventricular wall motion. (McConnells sign)
• Systolic flattening of the interventricular septum.
• Tricuspid valve insufficiency
• Increased pulmonary arterial pressure
• Inferior vena cava congestion
• Dilated pulmonary artery
• Right-sided cardiac thrombus.

20. HYPOTENSION

21. ABNORMAL FINDINGS
• Is the cause of hypotension cardiac in
etiology?
• Is it due to a pericardial effusion?
• Is is due to pump failure?

22. UNEXPLAINED HYPOTENSION
• Cardiogenic shock
• Poor LV contractility
• Hypovolemia
• Hyperdynamic ventricules
• Right ventricular infarct/large
pulmonary embolism
• Marked RV dilitation/hypokinesis
• Tamponade
• RV diastolic collapse

23. CARDIOGENIC SHOCK
• Dilated left
ventricle
• Hypocontractile
walls

24. • Small hyperdynamic
heart
• E/A < 1
• Small (< 20mm) IVC
with exaggerated
collapse with deep
inspiration
HYPOVOLEMIA

25. NON TRAUMATIC RESUSCITATION

26. DIRECT VISUALIZATION
• Is there effective myocardial contractility?
• Asystole
• Hypokinesis
• Normal
• Is there a pericardial effusion?

27. 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

28. ECHO IN PEA
• RV dilatation
• Hypoxic?? – Likely PE
• ECG – IMI with RV infarct?
• Profound hypokinesis
• Inotropic support
• Asystole
• Follow ACLS protocols
• Early data suggesting poor prognosis

29. ECHO IN PEA
• False positive cardiac motion
• Transthoracic pacemaker
• Positive pressure ventilation

30. PENETRATING CHEST TRAUMA

31. 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

32. Acute coronary syndrome
Echo in the assessment of complications

33. COMPLICATION OF AMI
• Haemodynamic states
Globally reduced LV contractility Hypovolumea
Right ventricular infarction Ischemic MR
• Mechanical Complications
- Papillary muscle rupture
- Ventricular septal rupture
- Free wall rupture and tamponade
• Other
- Left ventricular aneurysm
- Mural thrombus

34. Levine, R. A. N Engl J Med 2004;351:1681-1684
Ischaemic mitral regurgitation
EUROECHO CONGRESS
COPENHAGEN
TEACHING COURSE 2010

35. ISCHEMIC MITRAL REGURGITATION

41. Aortic dissection

42. 2
Aortic
Dissection
IH
PU

43. ECHO ALGORITHM

44. ROLE OF TEE
• Advantages: Ideal Dx test for AAS
• Safe
• Fast
• Bedside exam or in OR w/o transport
• Identifies extent and etiology of injury and associated
complications
• Sensitive (94-100%) and specific (77-100%)
• Disadvantages:
• Invasive
• Sedation
• TEE “blindspot” -- trachea between esophagus and upper
ascending aorta

45. TRUE VS. FALSE LUMEN

46. TRUE VS. FALSE LUMEN

47. 17
TEE. Additional information
I- Entry tear location and size

55. Prosthetic valve thrombosis

56. PROSTHETIC VALVE THROMBOSIS
Risk factors
• Inadequate oral anticoagulant
• Interruption of oral anticoagulation
(non cardiac surgery, pregnancy)
• Prosthetic type: Starr Edwards
• AF
• Low EF < 35%
• LA > 5cm
• Spontanous echo contrast
• MVR, TVR

57. ECHO
• 1. To assess hemodynamic severity
TTE and Doppler echo
• 2. To assess valve motion and clot burden
TEE and/or fluoroscopy

58. ECHOCARDIOGRAPHIC SIGNS OF
OBSTRUCTIVE PVT
• Reduced valve mobility
• Presence of thrombus
• Abnormal transprosthetic flow
• Central prosthetic regurgitation
• Elevated transprosthetic gradients
• Reduced prosthetic area

62. DEHISCENCE

65. Thank you