Transcript Emergency Medicine Echocardiography

Cardiac Ultrasound in
Emergency Medicine
Anthony J. Weekes MD, RDMS
Sarah A. Stahmer MD
For the SAEM US Interest Group
Primary Indications

Thoraco-abdominal trauma

Pulseless Electrical Activity

Unexplained hypotension

Suspicion of pericardial
effusion/tamponade
Secondary 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 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

Main cardiac views
Parasternal
 Subcostal
 Apical

Wall Motion
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 View
Most practical in
trauma setting
 Away from airway
and neck/chest
procedures

Subcostal View
Liver as acoustic
window
 Alternative to
apical 4 chamber
view

Subcostal View
Subcostal View
Subcostal View



Angle probe right to
see IVC
Response of IVC to
sniff indicates central
venous pressure
No collapse
– Tamponade
– CHF
– PE
– Pneumothorax
Parasternal Views
Next best imaging window
 Good for imaging LV
 Comparing chamber sizes
 Localized effusions
 Differentiating pericardial from pleural
effusions

Parasternal 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

Parasternal Long Axis
Parasternal Long Axis View
Parasternal 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
Parasternal Short Axis View
Parasternal Short Axis
Apical View
Difficult view to obtain
 Allows comparison of ventricular
chamber size
 Good window to assess septal/wall
motion abnormalities

Apical Views
Patient in left
lateral decubitus
position
 Probe placed at
PMI
 Probe marker at 6
o’clock (or right
shoulder)
 4 chamber view

Apical 4 chamber view
Marker pointed to
the floor
 Similar to
parasternal view
but apex well
visualized
 Angle beam
superiorly for 5
chamber view

Apical 4 chamber view
Apical 2 chamber view
Patient in left
lateral decubitus
position
 Probe placed at
PMI
 Probe marker at 3
o’clock
 2 chamber view

Apical 2 chamber view

Good look at inferior and anterior walls
Apical 2 chamber view
From apical 4,
rotate probe 90°
counterclockwise
 Good view for
long view of left
sided chambers
and mitral valve

Abnormal findings
Pericardial Effusion
Case 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

Echo 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
Size of the Pericardial
Effusion
Not Precise
 Small: confined to posterior space,
< 0.5cm
 Moderate: anterior and posterior,
0.5-2cm (diastole)
 Large: > 2cm

Pericardial Fluid: Subcostal
Clinical features of
Pericardial effusion
Pericardial fluid accumulation may
be clinically silent
 Symptoms are due to:

– mechanical compression of adjacent
structures
– Increased intrapericardial pressure
Pericardial
Effusion:Asymptomatic
Up to 40% of pregnant women
 Chronic hemodialysis patients

– one study showed 11% incidence of
pericardial effusion
AIDS
 CHF
 Hypoproteinemic states

Symptoms of Pericardial
Effusion
Chest discomfort (most common)
 Large effusions:

– Dyspnea
– Cough
– Fatigue
– Hiccups
– Hoarseness
– Nausea and abdominal fullness
Cardiac Tamponade

Increased intracardiac pressures

Limitation of ventricular diastolic
filling

Reduction of stroke volume and
cardiac output
Ventricular collapse in
diastole
Tamponade
Hypotension
Abnormal findings

Is the cause of hypotension cardiac in
etiology?

Is it due to a pericardial effusion?

Is is due to pump failure?
Unexplained Hypotension

Cardiogenic shock
– Poor LV contractility

Hypovolemia
– Hyperdynamic ventricules

Right ventricular infarct/large
pulmonary embolism
– Marked RV dilitation/hypokinesis

Tamponade
– RV diastolic collapse
Cardiogenic shock

Dilated left
ventricle

Hypocontractile
walls
Hypovolemia

Small chamber filling size

Aggressive wall motion

Flat IVC or exaggerated collapse
with deep inspiration
Massive PE or RV infarct
Dilated Right
ventricle
 RV hypokinesis
 Normal Left
ventricle function
 Stiff IVC

Case 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

Chest 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 Traumatic
Resuscitation
Direct Visualization

Is there effective myocardial
contractility?
– Asystole
– Myocardial “twitch”
– Hypokinesis
– Normal

Is there a pericardial effusion?
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
ECHO 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
ECHO in PEA

False positive cardiac motion
– Transthoracic pacemaker
– Positive pressure ventilation
Case 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 cardiac
contractions
Optimizing Performance

Assessing capture by transthoracic
pacemaker

Pericardiocentesis

Transvenous pacemaker placement
Optimizing Performance

Assessment of capture by transthoracic
pacemaker

Ettin D et al: Using ultrasound to
determine external pacer capture JEM
1999
Case 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
Clinical questions?
Why is she hypotensive?
 Volume loss

?Ruptured AAA
Pump failure
 Bedside sonography was performed
while we were waiting for the “labs”

Increase HR with PM “on”
What did this tell us?

Normal wall motion

No pericardial/pleural effusion

Good capture with the transthoracic PM
Asystole w/ Transthoracic PM
Optimizing performance

Pericardiocentesis
– Standard of care by cardiology/CT surgery
to use ECHO to guide aspiration
US GuidedPericardiocentesis

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
Large pericardial effusion
Technique
Optimizing performance
Placement of transvenous pacemaker
 Aguilera P et al: Emergency
transvenous cardiac pacing placement
using ultrasound guidance. Ann Emerg
Med 2000

Untimely 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

Penetrating Chest Trauma
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
Penetrating 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 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
Penetrating Cardiac Trauma
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 twodimensional echocardiography, the time to
diagnosis of penetrating cardiac injury has
decreased and both the survival rate and
neurologic outcome of survivors has improved.”
Stab wound to the chest
Penetrating Cardiac Trauma

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
Technical Problems
Subcutaneous air
 Pneumopericardium
 Mechanical ventilation
 Scanning limited by:

– Pain/tenderness
– Spinal immobilization
– Ongoing procedures
Technical Problems
Narrow intercostal spaces
 Obesity
 Muscular chest
 COPD
 Calcified rib cartilages
 Abdominal distention

Sonographic Pitfalls

Pericardial versus pleural fluid

Pericardial clot

Pericardial fat
Pericardial 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
Pleural and Pericardial fluid
Pleural effusion
Blunt Cardiac Trauma

Cardiac contusion

Cardiac rupture

Valvular disruption

Aortic disruption/dissection
Blunt 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
Cardiac Contusion

Akinetic anterior RV wall

Small pericardial effusion

Diminished ejection fraction
RV Contusion
Blunt Cardiac Trauma

Assess thoracic aorta
– Hematoma
– Intimal flap
– Abnormal contour
– Requires TEE and expertise!

Valvular dysfunction or septal rupture
– Requires expertise beyond our scope
Summary

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