Cardiac Us

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Cardiac Us

  1. 1. Emergency Cardiac Ultrasound Phillip D. Levy, MD, MPH, FACEP Assistant Professor of Emergency Medicine Wayne State University, Detroit Receiving Hospital
  2. 2. Introduction <ul><li>“ Stethoscope of the future” </li></ul><ul><li>Rapid visualization of cardiac structures and potential pathology </li></ul><ul><li>More sensitive and specific than physical exam, ECG or CXR </li></ul>
  3. 3. Primary Indications <ul><li>Suspected pericardial effusion or tamponade </li></ul><ul><li>Cardiac arrest </li></ul><ul><ul><li>PEA </li></ul></ul><ul><ul><li>Asystole vs. fine ventricular fibrillation </li></ul></ul><ul><li>Acute hypotension </li></ul><ul><li>Thoraco-abdominal trauma </li></ul>
  4. 4. Secondary Indications <ul><li>Acute chest pain </li></ul><ul><ul><li>Myocardial infarction </li></ul></ul><ul><ul><li>Pulmonary embolism </li></ul></ul><ul><ul><li>Aortic dissection </li></ul></ul><ul><li>Procedural guidance </li></ul><ul><ul><li>Pericardiocentesis </li></ul></ul><ul><ul><li>Detection of transcutaneous pacer capture </li></ul></ul><ul><ul><li>Placement of transvenous pacer </li></ul></ul>
  5. 5. Primary Clinical Concerns <ul><li>Is there cardiac activity ? </li></ul><ul><li>Is there an effusion ? </li></ul>
  6. 6. Anatomical Overview <ul><li>Right ventricle anterior, left posterior </li></ul><ul><li>Lungs provide poor transit medium </li></ul><ul><ul><li>Air = scatter </li></ul></ul><ul><ul><li>Use liver as acoustic window for subxyphoid approach </li></ul></ul><ul><li>Images quality can be limited by bony thorax </li></ul>
  7. 7. From: Yale Center for Advanced Instructional Media, Yale University. 2000
  8. 8. Technique <ul><li>Probe selection important </li></ul><ul><ul><li>Curved array: better contrast resolution </li></ul></ul><ul><ul><li>Phased array (sector): less rib shadowing </li></ul></ul><ul><li>Average frequency = 3.5 MHz </li></ul><ul><ul><li>2.5 MHz for larger patients </li></ul></ul><ul><ul><li>5.0 MHz for smaller patients </li></ul></ul><ul><li>Decrease depth and dynamic range </li></ul><ul><li>Reverse screen for true cardiac imaging </li></ul>
  9. 9. Normal Appearance <ul><li>Pericardium: uniform, brightly echogenic line </li></ul><ul><li>Myocardium: bulky, heterogeneous, hyperechoic material </li></ul><ul><li>Chambers: anechoic </li></ul>
  10. 10. Basic Image Planes
  11. 11. Subcostal <ul><li>Most useful overall </li></ul><ul><li>Standard view in FAST exam </li></ul><ul><li>Ideal for detection of effusion and cardiac motion </li></ul><ul><li>Diagonal view of heart </li></ul><ul><li>Liver functions as acoustic window </li></ul>
  12. 12. Subcostal <ul><li>Probe marker to patient’s right </li></ul><ul><li>Subxyphoid position </li></ul><ul><li>Shallow angle ( ~ 15 °) </li></ul><ul><li>Aimed at left shoulder </li></ul>
  13. 13. From: Yale Center for Advanced Instructional Media, Yale University. 2000
  14. 14. Subcostal
  15. 15. Parasternal Views <ul><li>Probe placed in left parasternal region at 2 nd to 4 th intercostal space </li></ul><ul><ul><li>Left lateral decubitus position improves images </li></ul></ul><ul><li>Long axis (right shoulder to left hip) </li></ul><ul><li>Short axis (left shoulder to right hip) </li></ul><ul><li>Enables differentiation between pericardial and pleural effusions </li></ul>
  16. 16. From: Gray, H. Anatomy of the Human Body 20 th ed. 2000 Short axis Long axis
  17. 17. Parasternal Long Axis <ul><li>Clearly displays </li></ul><ul><ul><li>Posterior wall of LV </li></ul></ul><ul><ul><li>Free wall of RV </li></ul></ul><ul><ul><li>Mitral and aortic valves </li></ul></ul><ul><ul><li>Proximal ascending aorta </li></ul></ul><ul><li>Probe marker faces left hip </li></ul>
  18. 18. From: Yale Center for Advanced Instructional Media, Yale University. 2000
  19. 19. Parasternal Long Axis
  20. 20. Parasternal Short Axis <ul><li>Cross-sectional view through ventricles </li></ul><ul><li>Rotate probe 90 ° toward right hip </li></ul><ul><li>Tilting probe cephalad to caudad allows imaging from aortic valve to apex </li></ul>
  21. 21. Parasternal Short Axis From: Yale Center for Advanced Instructional Media, Yale University. 2000
  22. 22. From: Yale Center for Advanced Instructional Media, Yale University. 2000
  23. 23. From: Yale Center for Advanced Instructional Media, Yale University. 2000
  24. 24. Parasternal Short Axis
  25. 25. Apical Views <ul><li>Left lateral decubitus position </li></ul><ul><li>Probe at apex (4 th or 5 th intercostal space) facing right shoulder </li></ul><ul><li>More difficult to obtain </li></ul><ul><li>Provides good images of chamber dimensions </li></ul>
  26. 26. Apical 4-chamber <ul><li>Good for evaluation of </li></ul><ul><ul><li>Wall motion </li></ul></ul><ul><ul><li>Masses or clots </li></ul></ul><ul><li>Probe marker toward right hip </li></ul>
  27. 27. From: Yale Center for Advanced Instructional Media, Yale University. 2000
  28. 28. Apical 4-chamber
  29. 29. Apical 2-chamber <ul><li>Less commonly used in ED setting </li></ul><ul><li>Shows anterior and inferior walls simultaneously </li></ul><ul><li>Rotate probe 90 ° </li></ul><ul><ul><li>Marker faces anterior and cephalad </li></ul></ul>
  30. 30. From: Yale Center for Advanced Instructional Media, Yale University. 2000
  31. 31. Apical 2-chamber
  32. 32. Functional Assessment <ul><li>Observation of dynamic changes of cardiac cycle </li></ul><ul><li>Estimation of ejection fraction </li></ul><ul><li>Evaluation of wall motion abnormalities </li></ul><ul><ul><li>Characterized as global or segmental </li></ul></ul><ul><ul><li>Hypokinesis: reduced movement </li></ul></ul><ul><ul><li>Akinesis: absent movement </li></ul></ul><ul><ul><li>Dyskinesia: paradoxical movement </li></ul></ul>
  33. 33. Normal Cardiac Cycle
  34. 34. Cardiac Measurements <ul><li>Chamber diameter </li></ul><ul><ul><li>Measured at right angle to long axis in both systolic and diastolic phases </li></ul></ul><ul><ul><li>Provide some functional information </li></ul></ul><ul><ul><li>Most useful as indication of ventricular strain </li></ul></ul><ul><li>Wall thickness </li></ul><ul><ul><li>Determination of hypertrophy </li></ul></ul>
  35. 35. Clinical Indications
  36. 36. Pericardial Effusion <ul><li>High degree of accuracy for EP’s 1 </li></ul><ul><ul><li>Sensitivity 99.9% </li></ul></ul><ul><ul><li>Specificity 98.1 % </li></ul></ul><ul><li>Anechoic stripe between visceral and parietal pericardium </li></ul><ul><ul><li>May be echogenic if malignant or coagulated </li></ul></ul><ul><li>Usually surrounds heart completely </li></ul><ul><ul><li>If anterior only, likely pericardial fat </li></ul></ul>1 Plummer D, et al. Abstract, SAEM Scientific Assembly 1995.
  37. 37. Pericardial Effusion <ul><li>Cardiac impairment dependent of rate of accumulation of fluid in pericardial space, not amount </li></ul><ul><ul><li>Up to 50 cc may be physiologic; usually not visible </li></ul></ul><ul><ul><li>Small collection < 1 cm thick </li></ul></ul><ul><ul><li>Large collections 1-2 cm thick </li></ul></ul><ul><li>Heart may swing freely with large effusions </li></ul>
  38. 38. Pericardial Effusion
  39. 39. Pericardial Fat
  40. 40. Pericardial Blood Clot
  41. 41. Tamponade <ul><li>Cardiac compromise from effusion </li></ul><ul><li>Beck’s triad seen in only 30 % 1 </li></ul><ul><li>Pulsus paridoxus late, non-specific </li></ul><ul><li>Ultrasound findings </li></ul><ul><ul><li>Systolic right atrial collapse </li></ul></ul><ul><ul><li>Diastolic right ventricular collapse </li></ul></ul><ul><ul><li>Equalization of ventricular pressures </li></ul></ul><ul><ul><li>Increased central venous pressure </li></ul></ul>1 Guberman BA, et al. Circulation 1981
  42. 42. Tamponade <ul><li>Respiratory variance in IVC can be used to estimate central venous pressure 1 </li></ul><ul><ul><li>IVC size Resp change RA pressure </li></ul></ul><ul><ul><li>< 1.5 cm Total collapse 0-5 cm/H 2 0 </li></ul></ul><ul><ul><li>1.5-2.5 > 50 % collapse 5-10 </li></ul></ul><ul><ul><li>1.5-2.5 < 50 % collapse 11-15 </li></ul></ul><ul><ul><li>>2.5 < 50 % collapse 16-20 </li></ul></ul><ul><ul><li>>2.5 No change > 20 </li></ul></ul>1 Ma, OJ and Mateer JR. Emergency Ultrasound, p 111. 2003
  43. 43. Effusion with Normal Dynamic Function
  44. 44. Tamponade with RV Collapse
  45. 45. Acute Hypotension <ul><li>Determination of etiology may allow rapid intervention </li></ul><ul><li>Tamponade </li></ul><ul><li>Cardiogenic shock </li></ul><ul><ul><li>Global hypokinesis </li></ul></ul><ul><ul><li>Left ventricular distention (MI) </li></ul></ul><ul><ul><li>Right ventricular distention </li></ul></ul><ul><ul><ul><li>PE or RV infarct </li></ul></ul></ul>
  46. 46. Acute Hypotension <ul><li>Hypovolemic shock </li></ul><ul><ul><li>Hyperdynamic cardiac activity </li></ul></ul><ul><ul><li>Small right chambers </li></ul></ul><ul><ul><li>Collapsed IVC </li></ul></ul><ul><li>Septic shock </li></ul><ul><ul><li>Hyperdynamic activity </li></ul></ul>
  47. 47. Cardiac Arrest Applications <ul><li>Can be used while CPR is in progress </li></ul><ul><li>Evaluate for cardiac activity </li></ul><ul><li>Treatment guidance for PEA </li></ul><ul><ul><li>Rule out tamponade </li></ul></ul><ul><ul><li>Dynamism of cardiac contraction </li></ul></ul><ul><ul><ul><li>Hyperdynamic may indicate hypovolemia </li></ul></ul></ul><ul><ul><ul><li>Hypodynamic may be ischemia or PE </li></ul></ul></ul><ul><li>Assess capture by transthoracic pacemaker 1 </li></ul>1 Ettin D, et al. JEM 1999
  48. 48. Blunt Thoracic Trauma <ul><li>Pericardial effusion </li></ul><ul><li>Traumatic aortic rupture </li></ul><ul><ul><li>Not ideal diagnostic modality (CT or TEE) </li></ul></ul><ul><ul><li>Look for </li></ul></ul><ul><ul><ul><li>Hematoma </li></ul></ul></ul><ul><ul><ul><li>Intimal flaps </li></ul></ul></ul><ul><ul><ul><li>Changes in vessel contour </li></ul></ul></ul><ul><li>Sternal or rib fractures </li></ul><ul><ul><li>Associated with underlying cardiac injury </li></ul></ul>
  49. 49. Blunt Thoracic Trauma <ul><li>Cardiac contusion </li></ul><ul><ul><li>Majority (73%) have signs of trauma 1 </li></ul></ul><ul><ul><li>Rarely associated with long-term impairment 2 </li></ul></ul><ul><ul><li>Limited diagnostic value of formal echo 3 </li></ul></ul><ul><ul><li>Screening ED ultrasound sufficient to rule out severe underlying injury 4 </li></ul></ul><ul><ul><ul><li>Assess for wall motion abnormalities and RV hypokinesis </li></ul></ul></ul>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
  50. 50. Penetrating Thoracic Trauma <ul><li>Goal is early detection of pericardial effusion BEFORE clinical signs develop </li></ul><ul><li>Hemopericardium is anechoic initially </li></ul><ul><ul><li>Echogenicity develops as blood coagulates </li></ul></ul><ul><li>Imaging may be limited </li></ul><ul><ul><li>Subcutaneous emphysema </li></ul></ul><ul><ul><li>Pneumopericadium </li></ul></ul><ul><ul><li>Mechanical ventilation </li></ul></ul>
  51. 51. Penetrating Thoracic Trauma <ul><li>Study of utilization in 261 pts 1 </li></ul><ul><ul><li>Sensitivity 100%, specificity 96.9% </li></ul></ul><ul><ul><li>PPV 81%, NPV 100% </li></ul></ul><ul><ul><li>Time to OR 12.1 +/- 5.9 min </li></ul></ul><ul><li>Comparison of outcomes 2 </li></ul><ul><ul><li>28 pts with ED cardiac ultrasound, 21 without </li></ul></ul><ul><ul><li>Survival: 100% in echo, 57.1% in non-echo </li></ul></ul><ul><ul><li>Time to diagnosis </li></ul></ul><ul><ul><ul><li>15 min echo, 42 min non-echo </li></ul></ul></ul>1 Rozycki GS, et al. J Trauma 1999 2 Plummer D et al. Ann Emerg Med 1992
  52. 52. Myocardial Infarct <ul><li>Determined by appearance of wall motion abnormalities </li></ul><ul><ul><li>Poor sensitivity 1,2 </li></ul></ul><ul><ul><li>Better specificity, but difficult to assess age of pathology 3,4 </li></ul></ul><ul><li>ED cardiac ultrasound may be most useful in ruling out other potential diagnoses </li></ul>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
  53. 53. Pulmonary Embolism <ul><li>Large PE may cause sonographically identifiable right heart strain </li></ul><ul><li>Wide range in accuracy 1-4 </li></ul><ul><ul><li>Sensitivity 50-93% </li></ul></ul><ul><ul><li>Specificity 81-98% </li></ul></ul><ul><li>Right heart strain: potential criteria for thrombolytic administration? 5 </li></ul>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
  54. 54. PE - Sonographic Findings <ul><li>Right ventricular dilation </li></ul><ul><ul><li>Parasternal long axis view </li></ul></ul><ul><ul><li>Normal diameter 21 ±1 mm </li></ul></ul><ul><ul><li>Abnormal > 25-30 mm </li></ul></ul><ul><li>Septal deviation to left ventricle </li></ul><ul><ul><li>Apical 4-chamber view </li></ul></ul><ul><li>Tricuspid regurgitation </li></ul><ul><li>Right ventricle hypokinesis, with wall thinning </li></ul>
  55. 55. Massive Pulmonary Embolism From: Goldhaber, SZ. NEJM 2002
  56. 56. Resolution After Thrombolytics From: Goldhaber, SZ. NEJM 2002
  57. 57. Aortic Dissection <ul><li>Difficult to detect by transthoracic echocardiogram </li></ul><ul><ul><li>Best seen on parasternal long axis view </li></ul></ul><ul><li>Appears as echogenic, mobile, linear flap within aorta lumen </li></ul><ul><li>May visualize double lumen </li></ul>
  58. 58. Other Findings <ul><li>Atrial myxoma </li></ul><ul><ul><li>Globular and echogenic, adherent to wall </li></ul></ul><ul><li>Mural thrombi </li></ul><ul><ul><li>Varying echogenicity </li></ul></ul><ul><li>Valvular vegetations </li></ul><ul><ul><li>Echogenic with irregular appearance </li></ul></ul><ul><li>Valvular dysfunction </li></ul><ul><ul><li>Best seen with color flow Doppler </li></ul></ul>
  59. 59. Atrial Myxoma
  60. 60. Mural Thrombus
  61. 61. Bacterial Endocarditis
  62. 62. Procedural Applications <ul><li>Pericardiocentesis </li></ul><ul><ul><li>Left parasternal approach or entry into largest area of fluid collection adjacent to the chest wall </li></ul></ul><ul><ul><li>Lower risk of cardiac or hepatic injury </li></ul></ul><ul><li>Transvenous pacing </li></ul><ul><ul><li>Allows highly accurate placement of pacing wire 1 </li></ul></ul>1 Aguilera P, et al. Ann Emerg Med 2000
  63. 63. Pericardiocentesis
  64. 64. Cardiac Ultrasound Pitfalls <ul><li>Not optimizing gain, depth and dynamic range </li></ul><ul><li>Settling for inferior images due to technical difficulty </li></ul><ul><li>Improper probe positioning </li></ul><ul><li>Mistaking pericardial fat for effusion </li></ul><ul><li>Mistaking clotted blood for normal anatomy </li></ul>
  65. 65. Case 1 <ul><li>77 yo female with hx of breast CA, in remission for 2 yrs, presents with gradually worsening SOB and CP </li></ul><ul><li>BP 90/50 HR 100 RR 26 T 99 SpO 2 82 % </li></ul><ul><li>Lungs with faint crackles, heart sounds distant </li></ul><ul><li>Abd exam nl; ext 2 + edema; neuro nl </li></ul><ul><li>Management ? </li></ul>
  66. 69. Case 2 <ul><li>22 yo old male, with stab wound to left chest, vital signs stable in field </li></ul><ul><li>Loses consciousness of arrival in ED </li></ul><ul><li>BP 60/palp HR 130 RR 6 T 98 SpO 2 80% </li></ul><ul><li>2 cm stab wound over L 4 th intercostal space; no other injury </li></ul><ul><li>Shallow breaths, no audible heart sounds </li></ul><ul><li>Management ? </li></ul>
  67. 72. Take Home Points <ul><li>Learn the skill but know your limitations ! </li></ul><ul><li>Be sure to observe dynamic function </li></ul><ul><li>Tilt, rotate or angulate probe to obtain optimal images </li></ul><ul><li>Use early, use often! </li></ul>

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