Uses of Echocardiography in Emergency Room

1. ECHOCARDIOGRAPHY IN
EMERGENCY
E S L A M M O H A M M E D , M . B . B . C H , M . S C . ,
C A R D I O L O G I S T

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

3. SECONDARY INDICATIONS
• Acute Cardiac Ischemia
• Pericardiocentesis
• External pacer capture
• Transvenous pacer placement

4. MAIN CLINICAL QUESTIONS
• What is the overall cardiac wall motion?
• Is there a pericardial effusion?

5. 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

6. MAIN CARDIAC VIEWS
Parasternal
Subcostal
Apical

7. WALL MOTION
•Normal
•Hyperkinetic
•Akinetic
•Dyskinetic: may fail to contract,
bulges outward at systole
•Hypokinetic

8. 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

9. SUBCOSTAL VIEW
Most practical in
trauma setting
Away from airway
and neck/chest
procedures

10. SUBCOSTAL VIEW
Liver as acoustic
window
Alternative to
apical 4 chamber
view

11. SUBCOSTAL VIEW

12. SUBCOSTAL VIEW

13. SUBCOSTAL VIEW
Angle probe right to
see IVC
Response of IVC to
sniff indicates central
venous pressure
No collapse
 Tamponade
 CHF
 PE
 Pneumothorax

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

15. 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

16. PARASTERNAL LONG AXIS

17. PARASTERNAL LONG AXIS VIEW

18. 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

19. PARASTERNAL SHORT AXIS VIEW

20. PARASTERNAL SHORT AXIS

21. APICAL VIEW
Difficult view to obtain
Allows comparison of ventricular chamber size
Good window to assess septal/wall motion abnormalities

22. APICAL VIEWS
Patient in left
lateral decubitus
position
Probe placed at PMI
Probe marker at 6
o’clock (or right
shoulder)
4 chamber view

23. APICAL 4 CHAMBER VIEW
Marker pointed to
the floor
Similar to
parasternal view
but apex well
visualized
Angle beam
superiorly for 5
chamber view

24. APICAL 4 CHAMBER VIEW

25. APICAL 2 CHAMBER VIEW
Patient in left lateral
decubitus position
Probe placed at PMI
Probe marker at 3
o’clock
2 chamber view

26. APICAL 2 CHAMBER VIEW
Good look at inferior and anterior walls

27. APICAL 2 CHAMBER VIEW
From apical 4,
rotate probe 90°
counterclockwise
Good view for long
view of left sided
chambers and
mitral valve

28. ABNORMAL FINDINGS
Pericardial Effusion

29. 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

31. 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

32. SIZE OF THE PERICARDIAL EFFUSION
Not Precise
Small: confined to posterior space, < 0.5cm
Moderate: anterior and posterior, 0.5-2cm (diastole)
Large: > 2cm

33. PERICARDIAL FLUID: SUBCOSTAL

34. CLINICAL FEATURES OF PERICARDIAL
EFFUSION
Pericardial fluid accumulation may be clinically silent
Symptoms are due to:
 mechanical compression of adjacent structures
 Increased intrapericardial pressure

35. PERICARDIAL EFFUSION:ASYMPTOMATIC
Up to 40% of pregnant women
Chronic hemodialysis patients
 one study showed 11% incidence of pericardial effusion
AIDS
CHF
Hypoproteinemic states

36. SYMPTOMS OF PERICARDIAL EFFUSION
Chest discomfort (most common)
Large effusions:
 Dyspnea
 Cough
 Fatigue
 Hiccups
 Hoarseness
 Nausea and abdominal fullness

37. CARDIAC TAMPONADE
Increased intracardiac pressures
Limitation of ventricular diastolic filling
Reduction of stroke volume and cardiac output

38. VENTRICULAR COLLAPSE IN DIASTOLE

39. TAMPONADE

40. HYPOTENSION

41. ABNORMAL FINDINGS
Is the cause of hypotension cardiac in etiology?
Is it due to a pericardial effusion?
Is is due to pump failure?

42. UNEXPLAINED HYPOTENSION
Cardiogenic shock
Poor LV contractility
Hypovolemia
Hyperdynamic ventricules
Right ventricular infarct/large
pulmonary embolism
Marked RV dilitation/hypokinesis
Tamponade
RV diastolic collapse

43. CARDIOGENIC SHOCK
Dilated left
ventricle
Hypocontractile
walls

44. HYPOVOLEMIA
Small chamber filling size
Aggressive wall motion
Flat IVC or exaggerated collapse with deep inspiration

45. MASSIVE PE OR RV INFARCT
Dilated Right
ventricle
RV hypokinesis
Normal Left
ventricle function
Stiff IVC

46. 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

49. 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

52. R sided leads

53. NON TRAUMATIC RESUSCITATION

54. DIRECT VISUALIZATION
Is there effective myocardial contractility?
 Asystole
 Myocardial “twitch”
 Hypokinesis
 Normal
Is there a pericardial effusion?

55. 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

56. 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

57. ECHO IN PEA
False positive cardiac motion

Transthoracic pacemaker

Positive pressure ventilation

58. 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

59. INEFFECTIVE CARDIAC CONTRACTIONS

60. OPTIMIZING PERFORMANCE
Assessing capture by transthoracic pacemaker
Pericardiocentesis
Transvenous pacemaker placement

61. OPTIMIZING PERFORMANCE
Assessment of capture by transthoracic pacemaker
Ettin D et al: Using ultrasound to determine external pacer capture JEM
1999

62. 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

63. CLINICAL QUESTIONS?
Why is she hypotensive?
Volume loss
?Ruptured AAA
Pump failure
Bedside sonography was performed while we were waiting
for the “labs”

64. INCREASE HR WITH PM “ON”

65. WHAT DID THIS TELL US?
Normal wall motion
No pericardial/pleural effusion
Good capture with the transthoracic PM

66. ASYSTOLE W/ TRANSTHORACIC PM

67. OPTIMIZING PERFORMANCE
Pericardiocentesis
 Standard of care by cardiology/CT surgery to use ECHO to
guide aspiration

68. 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

69. LARGE PERICARDIAL EFFUSION

70. TECHNIQUE

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

72. 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

74. PENETRATING CHEST TRAUMA

75. 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

76. 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

77. 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

78. 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 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.”

79. STAB WOUND TO THE CHEST

80. 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

81. TECHNICAL PROBLEMS
Subcutaneous air
Pneumopericardium
Mechanical ventilation
Scanning limited by:
 Pain/tenderness
 Spinal immobilization
 Ongoing procedures

82. TECHNICAL PROBLEMS
• Narrow intercostal spaces
• Obesity
• Muscular chest
• COPD
• Calcified rib cartilages
• Abdominal distention

83. SONOGRAPHIC PITFALLS
Pericardial versus pleural fluid
Pericardial clot
Pericardial fat

84. 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

85. PLEURAL AND PERICARDIAL FLUID

86. PLEURAL EFFUSION

87. BLUNT CARDIAC TRAUMA
Cardiac contusion
Cardiac rupture
Valvular disruption
Aortic disruption/dissection

88. 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

89. CARDIAC CONTUSION
Akinetic anterior RV wall
Small pericardial effusion
Diminished ejection fraction

90. RV CONTUSION

91. 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

92. 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

93. Thank You