Transcript Emergency Cardiac Ultrasound: “Questions”

Emergency
Cardiac Ultrasound:
“Questions”
Stephanie J. Doniger, MD FAAP
Emergency Cardiac US
Focused questions: heart, pericardium
Potentially life-threatening conditions
Yes-No questions
Questions
Is cardiac activity present?
Global cardiac hyper/hypo -kinesis?
Is there a pericardial effusion?
Tamponade?
Abnormal Cardiac US
Cardiac arrest, asystole
Pericardial Fluid
Hemopericardium
Cardiac Tamponade
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
M-Mode
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Wall Motion
LV dysfunction
Abnormal wall function
Abnormal ventric emptying/relaxation
Hypokinesia, akinesis, dyskinesia (paradoxic)
Hypokinesia
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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
Pericardial Effusions
Small
Moderate
Large
Location
Posterior
Inferior to LV
Extends to
apex
Circumscribes
heart
*Meas. @
Diastole
<10 mm
10-15 mm
>15 mm
*maximal width of pericardial stripe
Pericardial Effusion
Subxiphoid
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Pericardial Effusion
PSSA
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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
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
NOT
Pericardial Effusions
Pericardial fat pad
Anterior
Pleural effusions
Intraabdominal fluid
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
Tamponade: US
Circumferential pericardial effusion
“Scalloping” of RV
Diastolic collapse of RV (or RA)
Swinging heart
CCW rotational movement
Dilated IVC without inspiratory variation
Tamponade
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Tamponade
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Do you have questions?