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    Cardiac Ultrasound

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    ramon
    This document provides an overview of emergency cardiac ultrasound. It discusses: 1) The primary indications for cardiac ultrasound include suspected pericardial effusion/tamponade, cardiac arrest, acute hypotension, and thoraco-abdominal trauma. 2) Secondary indications include acute chest pain, procedural guidance, and functional assessment of the heart. 3) The technique involves using curved or phased array probes at 3.5MHz to obtain subcostal, parasternal, and apical views of the heart to evaluate for pathology and cardiac function.

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    Cardiac Ultrasound

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    ramon
    2K views72 pages
    This document provides an overview of emergency cardiac ultrasound. It discusses: 1) The primary indications for cardiac ultrasound include suspected pericardial effusion/tamponade, cardiac arrest, acute hypotension, and thoraco-abdominal trauma. 2) Secondary indications include acute chest pain, procedural guidance, and functional assessment of the heart. 3) The technique involves using curved or phased array probes at 3.5MHz to obtain subcostal, parasternal, and apical views of the heart to evaluate for pathology and cardiac function.

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    This document provides an overview of emergency cardiac ultrasound. It discusses: 1) The primary indications for cardiac ultrasound include suspected pericardial effusion/tamponade, cardiac arrest, acute hypotension, and thoraco-abdominal trauma. 2) Secondary indications include acute chest pain, procedural guidance, and functional assessment of the heart. 3) The technique involves using curved or phased array probes at 3.5MHz to obtain subcostal, parasternal, and apical views of the heart to evaluate for pathology and cardiac function.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT or read online from Scribd
    Download as ppt
    2K views72 pages

    Cardiac Ultrasound

    Uploaded by

    ramon
    This document provides an overview of emergency cardiac ultrasound. It discusses: 1) The primary indications for cardiac ultrasound include suspected pericardial effusion/tamponade, cardiac arrest, acute hypotension, and thoraco-abdominal trauma. 2) Secondary indications include acute chest pain, procedural guidance, and functional assessment of the heart. 3) The technique involves using curved or phased array probes at 3.5MHz to obtain subcostal, parasternal, and apical views of the heart to evaluate for pathology and cardiac function.

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    Emergency Cardiac

    Ultrasound
    Phillip D. Levy, MD, MPH, FACEP
    Assistant Professor of Emergency Medicine
    Wayne State University, Detroit Receiving Hospital
    Introduction
    • “Stethoscope of the future”
    • Rapid visualization of cardiac
    structures and potential pathology
    • More sensitive and specific than
    physical exam, ECG or CXR
    Primary Indications
    • Suspected pericardial effusion or
    tamponade
    • Cardiac arrest
    – PEA
    – Asystole vs. fine ventricular fibrillation
    • Acute hypotension
    • Thoraco-abdominal trauma
    Secondary Indications
    • Acute chest pain
    – Myocardial infarction
    – Pulmonary embolism
    – Aortic dissection
    • Procedural guidance
    – Pericardiocentesis
    – Detection of transcutaneous pacer
    capture
    – Placement of transvenous pacer
    Primary Clinical Concerns
    • Is there cardiac activity ?

    • Is there an effusion ?
    Anatomical Overview
    • Right ventricle anterior, left
    posterior
    • Lungs provide poor transit medium
    – Air = scatter
    – Use liver as acoustic window for
    subxyphoid approach
    • Images quality can be limited by bony
    thorax
    From: Yale Center for Advanced Instructional Media, Yale University. 2000
    Technique
    • Probe selection important
    – Curved array: better contrast resolution
    – Phased array (sector): less rib shadowing
    • Average frequency = 3.5 MHz
    – 2.5 MHz for larger patients
    – 5.0 MHz for smaller patients
    • Decrease depth and dynamic range
    • Reverse screen for true cardiac
    imaging
    Normal Appearance
    • Pericardium: uniform, brightly
    echogenic line
    • Myocardium: bulky, heterogeneous,
    hyperechoic material
    • Chambers: anechoic
    Basic Image Planes
    Subcostal
    • Most useful overall
    • Standard view in FAST exam
    • Ideal for detection of effusion and
    cardiac motion
    • Diagonal view of heart
    • Liver functions as acoustic window
    Subcostal
    • Probe marker to
    patient’s right
    • Subxyphoid position
    • Shallow angle (~ 15°)
    • Aimed at left shoulder
    From: Yale Center for Advanced Instructional Media, Yale University. 2000
    Subcostal
    Parasternal Views
    • Probe placed in left parasternal
    region at 2nd to 4th intercostal space
    – Left lateral decubitus position improves
    images
    • Long axis (right shoulder to left hip)
    • Short axis (left shoulder to right hip)
    • Enables differentiation between
    pericardial and pleural effusions
    Short axis Long axis
    From: Gray, H. Anatomy of the Human Body 20th ed. 2000
    Parasternal Long Axis
    • Clearly displays
    – Posterior wall of LV
    – Free wall of RV
    – Mitral and aortic
    valves
    – Proximal ascending
    aorta

    • Probe marker faces


    left hip
    From: Yale Center for Advanced Instructional Media, Yale University. 2000
    Parasternal Long Axis
    Parasternal Short Axis
    • Cross-sectional view
    through ventricles

    • Rotate probe 90°


    toward right hip
    • Tilting probe
    cephalad to caudad
    allows imaging from
    aortic valve to apex
    Parasternal Short Axis

    From: Yale Center for Advanced Instructional Media, Yale University. 2000
    From: Yale Center for Advanced Instructional Media, Yale University. 2000
    From: Yale Center for Advanced Instructional Media, Yale University. 2000
    Parasternal Short Axis
    Apical Views
    • Left lateral decubitus position
    • Probe at apex (4th or 5th intercostal
    space) facing right shoulder
    • More difficult to obtain
    • Provides good images of chamber
    dimensions
    Apical 4-chamber
    • Good for evaluation
    of
    – Wall motion
    – Masses or clots

    • Probe marker
    toward right hip
    From: Yale Center for Advanced Instructional Media, Yale University. 2000
    Apical 4-chamber
    Apical 2-chamber
    • Less commonly used
    in ED setting
    • Shows anterior and
    inferior walls
    simultaneously

    • Rotate probe 90°


    – Marker faces
    anterior and
    cephalad
    From: Yale Center for Advanced Instructional Media, Yale University. 2000
    Apical 2-chamber
    Functional Assessment
    • Observation of dynamic changes of
    cardiac cycle
    • Estimation of ejection fraction
    • Evaluation of wall motion
    abnormalities
    – Characterized as global or segmental
    – Hypokinesis: reduced movement
    – Akinesis: absent movement
    – Dyskinesia: paradoxical movement
    Normal Cardiac Cycle
    Cardiac Measurements
    • Chamber diameter
    – Measured at right angle to long axis in
    both systolic and diastolic phases
    – Provide some functional information
    – Most useful as indication of ventricular
    strain
    • Wall thickness
    – Determination of hypertrophy
    Clinical Indications
    Pericardial Effusion
    • High degree of accuracy for EP’s 1

    – Sensitivity 99.9%
    – Specificity 98.1 %
    • Anechoic stripe between visceral and
    parietal pericardium
    – May be echogenic if malignant or
    coagulated
    • Usually surrounds heart completely
    – If anterior only, likely pericardial fat
    1
    Plummer D, et al. Abstract, SAEM Scientific Assembly 1995.
    Pericardial Effusion
    • Cardiac impairment dependent of rate
    of accumulation of fluid in pericardial
    space, not amount
    – Up to 50 cc may be physiologic; usually
    not visible
    – Small collection < 1 cm thick
    – Large collections 1-2 cm thick
    • Heart may swing freely with large
    effusions
    Pericardial Effusion
    Pericardial Fat
    Pericardial Blood Clot
    Tamponade
    • Cardiac compromise from effusion
    • Beck’s triad seen in only 30 % 1
    • Pulsus paridoxus late, non-specific
    • Ultrasound findings
    – Systolic right atrial collapse
    – Diastolic right ventricular collapse
    – Equalization of ventricular pressures
    – Increased central venous pressure

    1
    Guberman BA, et al. Circulation 1981
    Tamponade
    • Respiratory variance in IVC can be
    used to estimate central venous
    pressure 1

    IVC size Resp change RA pressure


    < 1.5 cm Total collapse 0-5 cm/H20
    1.5-2.5 > 50 % collapse 5-10
    1.5-2.5 < 50 % collapse 11-15
    >2.5 < 50 % collapse 16-20
    >2.5 No change > 20
    1
    Ma, OJ and Mateer JR. Emergency Ultrasound, p 111. 2003
    Effusion with Normal
    Dynamic Function
    Tamponade with RV
    Collapse
    Acute Hypotension
    • Determination of etiology may allow
    rapid intervention
    • Tamponade
    • Cardiogenic shock
    – Global hypokinesis
    – Left ventricular distention (MI)
    – Right ventricular distention
    • PE or RV infarct
    Acute Hypotension
    • Hypovolemic shock
    – Hyperdynamic cardiac activity
    – Small right chambers
    – Collapsed IVC
    • Septic shock
    – Hyperdynamic activity
    Cardiac Arrest Applications
    • Can be used while CPR is in progress
    • Evaluate for cardiac activity
    • Treatment guidance for PEA
    – Rule out tamponade
    – Dynamism of cardiac contraction
    • Hyperdynamic may indicate hypovolemia
    • Hypodynamic may be ischemia or PE
    • Assess capture by transthoracic
    pacemaker 1
    1
    Ettin D, et al. JEM 1999
    Blunt Thoracic Trauma
    • Pericardial effusion
    • Traumatic aortic rupture
    – Not ideal diagnostic modality (CT or TEE)
    – Look for
    • Hematoma
    • Intimal flaps
    • Changes in vessel contour
    • Sternal or rib fractures
    – Associated with underlying cardiac injury
    Blunt Thoracic Trauma
    • Cardiac contusion
    – Majority (73%) have signs of trauma 1
    – Rarely associated with long-term
    impairment 2
    – Limited diagnostic value of formal echo 3
    – Screening ED ultrasound sufficient to rule
    out severe underlying injury 4
    • Assess for wall motion abnormalities and RV
    hypokinesis Snow, et al. Surgery 1982
    1

    2
    Sturaitis M, et al.. Arch Intern Med 1986
    3
    Maenza RL, et al. Am J Emerg Med 1996
    4
    Welch RD. Emerg Med Clin North Am 2001
    Penetrating Thoracic
    Trauma
    • Goal is early detection of pericardial
    effusion BEFORE clinical signs
    develop
    • Hemopericardium is anechoic initially
    – Echogenicity develops as blood
    coagulates
    • Imaging may be limited
    – Subcutaneous emphysema
    – Pneumopericadium
    – Mechanical ventilation
    Penetrating Thoracic
    Trauma
    • Study of utilization in 261 pts 1

    – Sensitivity 100%, specificity 96.9%


    – PPV 81%, NPV 100%
    – Time to OR 12.1 +/- 5.9 min
    • Comparison of outcomes 2

    – 28 pts with ED cardiac ultrasound, 21


    without
    – Survival: 100% in echo, 57.1% in non-echo
    – Time to diagnosis
    • 15 min echo, 42 min non-echo 1
    Rozycki GS, et al. J Trauma 1999
    2
    Plummer D et al. Ann Emerg Med 1992
    Myocardial Infarct
    • Determined by appearance of wall
    motion abnormalities
    – Poor sensitivity 1,2
    – Better specificity, but difficult to
    assess age of pathology 3,4
    • ED cardiac ultrasound may be most
    useful in ruling out other potential
    diagnoses 1
    Levitt MA, et al. Ann Emerg Med 1996
    2
    Muttreja M. Echocardiography 1999
    3
    Horowitz RS, et al. Circulation 1982
    4
    Sabia P, et al. Circulation 1991
    Pulmonary Embolism
    • Large PE may cause sonographically
    identifiable right heart strain
    • Wide range in accuracy 1-4
    – Sensitivity 50-93%
    – Specificity 81-98%
    • Right heart strain: potential criteria
    for thrombolytic administration? 5
    1
    Kasper W, et al. Am Heart J 1986
    2
    Nazeryollas P, et al. Eur Heart J 1996
    3
    Perrier A, et al. Int J Cardiol 1998
    4
    Rudoni R, et al. J Emerg Med 2001
    5
    Konstantinides S, et al. NEJM 2002
    PE - Sonographic Findings
    • Right ventricular dilation
    – Parasternal long axis view
    – Normal diameter 21±1 mm
    – Abnormal > 25-30 mm
    • Septal deviation to left ventricle
    – Apical 4-chamber view
    • Tricuspid regurgitation
    • Right ventricle hypokinesis, with wall
    thinning
    Massive Pulmonary Embolism

    From: Goldhaber, SZ. NEJM 2002


    Resolution After
    Thrombolytics

    From: Goldhaber, SZ. NEJM 2002


    Aortic Dissection
    • Difficult to detect by transthoracic
    echocardiogram
    – Best seen on parasternal long axis view
    • Appears as echogenic, mobile, linear
    flap within aorta lumen
    • May visualize double lumen
    Other Findings
    • Atrial myxoma
    – Globular and echogenic, adherent to wall
    • Mural thrombi
    – Varying echogenicity
    • Valvular vegetations
    – Echogenic with irregular appearance
    • Valvular dysfunction
    – Best seen with color flow Doppler
    Atrial Myxoma
    Mural Thrombus
    Bacterial Endocarditis
    Procedural Applications
    • Pericardiocentesis
    – Left parasternal approach or entry into
    largest area of fluid collection adjacent
    to the chest wall
    – Lower risk of cardiac or hepatic injury
    • Transvenous pacing
    – Allows highly accurate placement of
    pacing wire 1

    1
    Aguilera P, et al. Ann Emerg Med 2000
    Pericardiocentesis
    Cardiac Ultrasound Pitfalls
    • Not optimizing gain, depth and
    dynamic range
    • Settling for inferior images due to
    technical difficulty
    • Improper probe positioning
    • Mistaking pericardial fat for effusion
    • Mistaking clotted blood for normal
    anatomy
    Case 1
    • 77 yo female with hx of breast CA, in
    remission for 2 yrs, presents with
    gradually worsening SOB and CP
    • BP 90/50 HR 100 RR 26 T 99 SpO2 82 %
    • Lungs with faint crackles, heart sounds
    distant
    • Abd exam nl; ext 2 + edema; neuro nl

    • Management ?
    Case 2
    • 22 yo old male, with stab wound to
    left chest, vital signs stable in field
    • Loses consciousness of arrival in ED
    • BP 60/palp HR 130 RR 6 T 98 SpO2 80%
    • 2 cm stab wound over L 4th intercostal
    space; no other injury
    • Shallow breaths, no audible heart sounds

    • Management ?
    Take Home Points
    • Learn the skill but know your
    limitations !
    • Be sure to observe dynamic function
    • Tilt, rotate or angulate probe to
    obtain optimal images
    • Use early, use often!

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