Cardiac Us
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Cardiac Us Cardiac Us Presentation Transcript

  • 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
    View slide
  • Secondary Indications
    • Acute chest pain
      • Myocardial infarction
      • Pulmonary embolism
      • Aortic dissection
    • Procedural guidance
      • Pericardiocentesis
      • Detection of transcutaneous pacer capture
      • Placement of transvenous pacer
    View slide
  • 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 2 nd to 4 th 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
  • From: Gray, H. Anatomy of the Human Body 20 th ed. 2000 Short axis Long axis
  • 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 (4 th or 5 th 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/H 2 0
      • 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
    1 Snow, et al. Surgery 1982 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 SpO 2 82 %
    • Lungs with faint crackles, heart sounds distant
    • Abd exam nl; ext 2 + edema; neuro nl
    • Management ?
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  • 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 SpO 2 80%
    • 2 cm stab wound over L 4 th intercostal space; no other injury
    • Shallow breaths, no audible heart sounds
    • Management ?
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  • 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!