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
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
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
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
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
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
30.
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
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
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
47.
48.
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
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
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”
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
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
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. 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.”
Penetrating Cardiac Trauma
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