Cardiac Ultrasound in Emergency Medicine

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Cardiac Ultrasound in Emergency Medicine

• Anthony J. Weekes MD, RDMS
• Sarah A. Stahmer MD
• For the SAEM US Interest Group

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Primary Indications

• Thoraco-abdominal trauma
• Pulseless Electrical Activity
• Unexplained hypotension
• Suspicion of pericardial effusion/tamponade

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Secondary Indications

• Acute Cardiac Ischemia
• Pericardiocentesis
• External pacer capture
• Transvenous pacer placement

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Main Clinical Questions

• What is the overall cardiac wall motion?
• Is there a pericardial effusion?

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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

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Main cardiac views

• Parasternal
• Subcostal
• Apical

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Wall Motion

• Normal
• Hyperkinetic
• Akinetic
• Dyskinetic may fail to contract, bulges outward
  at systole
• Hypokinetic

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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\

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Subcostal View

• Most practical in trauma setting
• Away from airway and neck/chest procedures

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Subcostal View

• Liver as acoustic window
• Alternative to apical 4 chamber view

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Subcostal View
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Subcostal View
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Subcostal View

• Angle probe right to see IVC
• Response of IVC to sniff indicates central venous
  pressure
• No collapse
• Tamponade
• CHF
• PE
• Pneumothorax

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Parasternal Views

• Next best imaging window
• Good for imaging LV
• Comparing chamber sizes
• Localized effusions
• Differentiating pericardial from pleural
  effusions

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Parasternal Long Axis

• Near sternum
• 3rd or 4th left intercostal space
• Marker pointed to patients right shoulder (or
  left hip if screen is not reversed for cardiac
  imaging)
• Rotate enough to elongate cardiac chambers

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Parasternal Long Axis
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Parasternal Long Axis View
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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

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Parasternal Short Axis View
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Parasternal Short Axis
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Apical View

• Difficult view to obtain
• Allows comparison of ventricular chamber size
• Good window to assess septal/wall motion
  abnormalities

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Apical Views

• Patient in left lateral decubitus position
• Probe placed at PMI
• Probe marker at 6 oclock (or right shoulder)
• 4 chamber view

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Apical 4 chamber view

• Marker pointed to the floor
• Similar to parasternal view but apex well
  visualized
• Angle beam superiorly for 5 chamber view

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Apical 4 chamber view
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Apical 2 chamber view

• Patient in left lateral decubitus position
• Probe placed at PMI
• Probe marker at 3 oclock
• 2 chamber view

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Apical 2 chamber view

• Good look at inferior and anterior walls

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Apical 2 chamber view

• From apical 4, rotate probe 90 counterclockwise
• Good view for long view of left sided chambers
  and mitral valve

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Abnormal findings

• Pericardial Effusion

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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

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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

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Size of the Pericardial Effusion

• Not Precise
• Small confined to posterior space, lt 0.5cm
• Moderate anterior and posterior, 0.5-2cm
  (diastole)
• Large gt 2cm

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Pericardial Fluid Subcostal
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Clinical features of Pericardial effusion

• Pericardial fluid accumulation may be clinically
  silent
• Symptoms are due to
• mechanical compression of adjacent structures
• Increased intrapericardial pressure

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Pericardial EffusionAsymptomatic

• Up to 40 of pregnant women
• Chronic hemodialysis patients
• one study showed 11 incidence of pericardial
  effusion
• AIDS
• CHF
• Hypoproteinemic states

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Symptoms of Pericardial Effusion

• Chest discomfort (most common)
• Large effusions
• Dyspnea
• Cough
• Fatigue
• Hiccups
• Hoarseness
• Nausea and abdominal fullness

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Cardiac Tamponade

• Increased intracardiac pressures
• Limitation of ventricular diastolic filling
• Reduction of stroke volume and cardiac output

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Ventricular collapse in diastole
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Tamponade
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Hypotension
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Abnormal findings

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

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Unexplained Hypotension

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

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Cardiogenic shock

• Dilated left ventricle
• Hypocontractile walls

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Hypovolemia

• Small chamber filling size
• Aggressive wall motion
• Flat IVC or exaggerated collapse with deep
  inspiration

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Massive PE or RV infarct

• Dilated Right ventricle
• RV hypokinesis
• Normal Left ventricle function
• Stiff IVC

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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

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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

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R sided leads
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Non Traumatic Resuscitation
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Direct Visualization

• Is there effective myocardial contractility?
• Asystole
• Myocardial twitch
• Hypokinesis
• Normal
• Is there a pericardial effusion?

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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

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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

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ECHO in PEA

• False positive cardiac motion
• Transthoracic pacemaker
• Positive pressure ventilation

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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

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Ineffective cardiac contractions
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Optimizing Performance

• Assessing capture by transthoracic pacemaker
• Pericardiocentesis
• Transvenous pacemaker placement

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Optimizing Performance

• Assessment of capture by transthoracic pacemaker
• Ettin D et al Using ultrasound to determine
  external pacer capture JEM 1999

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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

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Clinical questions?

• Why is she hypotensive?
• Volume loss
• ?Ruptured AAA
• Pump failure
• Bedside sonography was performed while we were
  waiting for the labs

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Increase HR with PM on
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What did this tell us?

• Normal wall motion
• No pericardial/pleural effusion
• Good capture with the transthoracic PM

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Asystole w/ Transthoracic PM
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Optimizing performance

• Pericardiocentesis
• Standard of care by cardiology/CT surgery to use
  ECHO to guide aspiration

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US 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

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Large pericardial effusion
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Technique
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Optimizing performance

• Placement of transvenous pacemaker
• Aguilera P et al Emergency transvenous cardiac
  pacing placement using ultrasound guidance. Ann
  Emerg Med 2000

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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

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Penetrating Chest Trauma
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Penetrating Cardiac Trauma

• Physicians ability to determine whether there is
  a hemodynamically significant effusion is poor
• Becks Triad
• Dependent on patient cardiovascular status
• Findings are often late
• Determinants of hemodynamic compromise
• Size of the effusion
• Rate of formation

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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

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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 NPV100
• Time interval BUS to OR 12.1 /- 5.9 min

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Penetrating Cardiac Trauma

• Emergency Department Echocardiography Improves
  Outcome in Penetrating Cardiac Injury
• Plummer D, et al. Ann Emerg Med 21709-712,
  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.

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Stab wound to the chest
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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

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Technical Problems

• Subcutaneous air
• Pneumopericardium
• Mechanical ventilation
• Scanning limited by
• Pain/tenderness
• Spinal immobilization
• Ongoing procedures

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Technical Problems

• Narrow intercostal spaces
• Obesity
• Muscular chest
• COPD
• Calcified rib cartilages
• Abdominal distention

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Sonographic Pitfalls

• Pericardial versus pleural fluid
• Pericardial clot
• Pericardial fat

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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

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Pleural and Pericardial fluid
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Pleural effusion
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Blunt Cardiac Trauma

• Cardiac contusion
• Cardiac rupture
• Valvular disruption
• Aortic disruption/dissection

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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

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Cardiac Contusion

• Akinetic anterior RV wall
• Small pericardial effusion
• Diminished ejection fraction

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RV Contusion
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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

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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