emergency echocardiography in critically ill patients

1. EMERGENCY
ECHOCARDIOGRAPHY IN
CRITICALLY ILL PATIENTS WITH
SHOCK

2. • Emergency echocardiography refers to
use of echo in the assessment of patients
with unstable cardiovascular diseases
• It should be distinguished from routine
use of echo
• Eg:stress echo done in clinically stable
patients

3. Advantages
Cheap
Portable
Widely available
Non invasive, no toxic contrast, no radiation

4. Disadvantages of TTE in ITU
Poor ECHO images in:
•Obese
•COAD/hyperinflated chest
•Chest wall deformity
•Oedema
•Post cardiac surgery –wounds, pain, drains

5. Rationale for use of Echo
• Point-of care echocardiography in the
management of the critically ill patient
• Provides rapid assessment of cardiac function
and physiology
• Complements data available from standard
invasive hemodynamic monitoring
• Both a diagnostic and monitoring tool for rapid
bedside assessment of cardiovascular
pathophysiology in the critically ill

6. WHY CHALLENGING???
• Key decisions should be made quickly
• A stressful condition
• Often accompained by difficulties in
acquiring good images
• Physicians in charge are frequently forced
to interpret suboptimal studies
• Limited time for consultation with
collegues

10. ECHOCARDIOGRAPHIC TECHNIQUES
IN EMERGENCY SETTINGS
1)TTE
• Main source of information in emergency
setting
• 2D and colour doppler techniques-
cornerstones
• Newer techniques like TDI and myocardial
deformation imaging,3D echo currently
have limited role in emergency situations

11. CLINICAL INDICATIONS
• 1- Hemodynamic instability and/or hypoxemia of unclear etiology
(i) Suspected tamponade
(ii) Pulseless electrical activity (PEA) can be the presenting symptom for:
• Tamponade
• Acute massive internal hemorrhage
• Massive pulmonary embolism
• Tension pneumothorax
• 2- Aortic dissection 3- Acute coronary syndromes
• 4- Acute valvular pathology, Prosthetic valve malfunction
• 5- Infective endocarditis 6- Massive Pulmonary embolism
• 7- Acute embolic event
• 8- Critically ill patients due to non-cardiac illness: cardiac function and left
ventricular (LV) filling may be crucial to guide fluid resuscitation:
•(a) septic shock and (b) diabetic ketoacidosis.

12. 2)TEE

14. EMERGENCY ROOM??....CCU/ICU/cath lab

15. ECHO ALGORITHM
Unstable patient with shock or pulmonary
oedema
Quick targeted Echo (minimum views subcostal ,
Apical)
moderate
pericardial effusion
Compressed
RA/RV
Collapsed IVC
Severely
enlarged akinetic
RV
Severe
hypokinetic LV
Small hyperdynamic
heart
 Collapsed IVC
Assume
tamponade
Assume
pulmonary
embolism
Assume
acute pump
failure MI
Myocarditis)
Assume severe
hypovolemia
Major internal
bleeding
Sepsis

16. VARIOUS PROTOCOLS
Basis of symptoms
RUSH PROTOCOL
FATE AND FEEL PROTOCOL

17. SYMPTOM:ACUTE CHEST PAIN

18. SYMPTOM:ACUTE DYSPNOEA

19. OTHERS….

20. Emergency Echo
• FEEL: focused echocardiography evaluation
in life support
• FATE: focused assessed transthoracic echo
Goals
• acquire standard TTE views in ACLS
compliant manner
• recognise major causes of arrest/ shock
• recognise when referral for second opinion

21. FATE - interpretation
• Look for obvious pathology
• Masses, vegetations, intra thoracic foreign bodies
• Assess morphology/dimensions
• Assess myocardial function
• Assess valves
• Image pleura on both side
• Relate the information to the clinical context

38. Step 1: The Pump
• The first step in evaluation of
the patient in shock is
determination of cardiac status,
termed for simplicity “the
pump.”
•Clinicians caring for the
patient in shock should begin
with a goal-directed
echocardiogram looking for
three specific findings:
1.pericardial effusion,
2.left ventricular contractility,
3.right ventricular dilation.

39. CARDIAC TAMPONADE

40. (A) Pericardial Effusions and Cardiac
Tamponade.
• Small effusions may be seen as a thin stripe inside
the pericardial space
• larger effusions tend to wrap circumferentially around
the heart.
• Fresh fluid or blood tends to have a dark or anechoic
appearance, whereas clotted blood or exudates may
have a lighter or more echogenic appearance

41. DIAGNOSIS
• Echocardiogram (tamponade is clinical diagnosis)
• Pericardial effusion
• Early diastolic collapse of the right ventricular free wall
• Late diastolic compression/collapse of the right atrium
• Swinging of the heart in its sac
• Respiratory variation of mitral and tricuspid flow
• Dilated IVC (collapse < 50%)

45. Tamponade physiology

46. ECHO GUIDED- PERICARDIOCENTESIS
If tamponade is identified and the patient also
displays unstable hemodynamics, an emergent
pericardiocentesis is indicated.

47. (B) Left Ventricular Contractility
Assessment will give a rapid
determination of the strength
of “the pump,” which can be
critical in guiding fluid
resuscitation. The examination
focuses on evaluating motion of
the left ventricular walls by a
visual estimation of the volume
change from diastole to systole

50. M-mode can be used to graphically depict
the move- ments of the left ventricular
walls through the cardiac cycle. Placing
the cursor across the left ventricle just
beyond the tips of the mitral valve
leaflets, the resultant M-mode tracing
allows measurements of the chamber
diameter in both systole and diastole. A
percentage known as fractional
shortening is calculated according to the
following formula: [(EDD − ESD)/EDD] ×
100, where ESD is end-systolic diameter,
measured at the smallest dimension
between the ventricular walls, and EDD is
the end-diastolic diameter where the
distance is greatest. In general, fractional
short- ening of 30–45% correlates to
normal ejection fraction

51. The EPSS is the minimal distance
between the E-wave and the septum
and is normally less than 7mm
Studies have demonstrated that EPSS
greater than 1 cm reliably correlates
with a low ejection fraction . Another
study demonstrated that Emergency
Physicians are able to accurately
estimate ejection fraction using EPSS
highlighting its value in identifying
patients with abnormal contractility.
An important caveat is that EPSS
does not reflect systolic dysfunction
in the setting of mitral valve
abnormalities (stenosis,
regurgitation), aortic regurgitation, or
extreme left ventricle hypertrophy.

52. Right Ventricular Size
• The third goal-directed examination of the heart
• focuses on the evaluation of right heart strain, a
potential sign of a large pulmonary embolus in the
patient in shock.
• Any condition that causes a sudden pressure
increase within the pulmonary vascular circuit will
result in acute dilation of the right side of the heart.
• On bedside echocardiography, the normal ratio of
the left- to-right ventricle is 1 : 0.6.
• Dilation of the right ventricle, especially to a size
greater than the left ventricle, may be a sign of a
large pulmonary embolus in the hypotensive patient

55. PULMONARY EMBOLISM

56. ECHOCARDIOGRAPHY IN PE: TO
IDENTIFY RV OVERLOAD
• RV dilatation.
• Abnormal right ventricular wall motion. (McConnells sign)
• Systolic flattening of the interventricular septum.
• Tricuspid valve insufficiency
• Increased pulmonary arterial pressure
• Inferior vena cava congestion
• Dilated pulmonary artery
• Right-sided cardiac thrombus.

60. PNEUMOTHORAX

61. TANK(A) Fullness of the Tank: Inferior
Vena Cava and Internal Jugular Veins.
Looking at both the relative vessel size and its respiratory
dynamics, the IVC provides an indication of intravascular
volume and has been used to estimate the central venous
pressure
M-mode sonography of the IVC provides an excellent means
to measure and document the degree of inspiratory IVC
collapse.

63. (B) Leakiness of the Tank OR TANK
OVERLOAD
Finally, lung ultrasound can identify pulmonary edema, a sign
often indicative of “tank overload” and “tank leakiness” with
fluid accumulation in the lung parenchyma
To assess for pulmonary edema with ultrasound, the lungs are
scanned with a low-frequency phased array transducer in the
anterolateral chest between the second and fifth rib
interspaces.
Examining the lungs from a more lateral orientation, or even
from a posterior approach, increases the sensitivity of this
technique
Detection of pulmonary edema with ultrasound relies on
seeing a special type of lung ultrasound artifact, termed
ultrasound B-lines or “lung rockets.” These B-lines appear as a
series of diffuse, brightly echogenic lines originating from the
pleural line and projecting posteriorly in a fanlike pattern

64. (C) Compromise of the Tank:
Pneumothorax
• may occur as a result of a tension pneumothorax, where
venous return to the heart is limited by increased thoracic
pressure.
• For this exam, the patient should be positioned in a supine
position. A high frequency linear array probe is positioned
at the most anterior point of the thorax to identify the
pleural line. This line appears as an echogenic horizontal
line, located approximately a half-centimeter deep to the
ribs. The pleural line consists of the closely opposed visceral
and parietal pleura.
• In the normal lung, the visceral and parietal pleura can be
seen to slide against each other, with a glistening or
shimmering appearance as the patient breathes.
• “Comet-tail” artifacts, or vertical hyperechoic lines, may be
seen to extend posteriorly from the opposed pleura
• presence of lung sliding with comet-tails excludes a
pneumothorax.

65. • In contrast, a pneumothorax results in air collecting
between the layers of the parietal and visceral pleura,
preventing the ultrasound beam from detecting normal lung
sliding and vertical comet-tails
• The pleural line will consist only of the parietal layer, seen
as a single stationary line. While the line may be seen to
move anteriorly and posteriorly due to exaggerated chest
wall motions, noted often in cases of severe respiratory
distress, the characteristic horizontal sliding of the pleural
line will not be seen.
• The presence or absence of lung sliding can be graphically
depicted using M-mode Doppler.
• A normal image will depict “waves on the beach.” Closest to
the probe, the stationary anterior chest wall demonstrates
a linear pattern, while posterior to the pleural line the
presence of lung motion demonstrates an irregular,
granular pattern. In pneumothorax, M-mode Doppler
ultrasound will only show repeating horizontal lines,
indicating a lack of lung sliding in a finding known as the
“barcode” or “stratosphere sign”

68. Step 3: The Pipes
The third and final step in the RUSH exam is to examine “the
pipes,” looking first at the arterial side of the circulatory
system, and secondly, at the venous side
Vascular catastrophes, such as a ruptured abdominal aortic
aneurysm (AAA) or an aortic dissection, are life-threatening
causes of hypotension. The survival of such patients may
often be measured in minutes, and the ability to quickly
diagnose these diseases is crucial.

69. (A) Rupture of the Pipes: Aortic
Aneurysm and Dissection.
Examination of the abdominal aorta
along its entire course is essential to
rule out an aneurysm, paying special
attention to the aorta below the renal
arteries where most AAAs are located
An AAA is diagnosed when the vessel
diameter exceeds 3 cm.
Measurements should be obtained in
the short-axis plane, measuring the
maximal diameter of the aorta from
outer wall to outer wall and should
include any thrombus present in the
vessel
Smaller aneurysms may be
symptomatic, although rupture is
more common with aneurysms
measuring larger than 5 cm

70. • Rupture of an AAA typically occurs into the retroperitoneal
space, which is an area difficult to visualize Therefore, in an
unstable patient with clinical symptoms consistent of this
condition and an AAA diagnosed by echo, rupture should be
assumed and emergency treatment expedited.
• Another crucial part of “the pipes” protocol is evaluation for
an aortic dissection.

71. ECHO ALGORITHM

72. TTE in aortic dissection
► Intimal flap
► Aortic insufficiency
► Presence of pericardial effusion
► Aortic root dilatation
► Regional wall motion abnormalities
Fast,bedside exam without transport.
► Can image the entire thoracic aorta except for a small
portion of the distal ascending aorta near the proximal arch.
► Identifies extent,intimal tear location,true and false
lumens and complications

73. ROLE OF TEE
• Advantages: Ideal Dx test for AAS
• Safe
• Fast
• Bedside exam or in OR w/o transport
• Identifies extent and etiology of injury and associated
complications
• Sensitive (94-100%) and specific (77-100%)
• Disadvantages:
• Invasive
• Sedation
• TEE “blindspot” -- trachea between esophagus and upper
ascending aorta

74. TRUE VS. FALSE LUMEN

75. TEE. Additional information
I- Entry tear location and size

76. • Sonographic findings suggestive of the diagnosis include
the presence of aortic root dilation and an aortic intimal flap
• The parasternal long- axis view of the heart permits an
evaluation of the proximal aortic root.
• A Stanford Class A aortic dissection will often lead to a
widened aortic root In this type of dissection, aortic
regurgitation or pericardial effusion may also be seen.
• An echogenic intimal flap may be recognized within the
dilated root or along the course of the aorta. The
suprasternal view allows further imaging of the aortic arch.
A Stanford Class B aortic dissection may be detected by
noting the presence of an intimal flap in the descending
aorta or in the abdominal aorta in cases that propagate
below the diaphragm. Color flow Doppler imaging can be
used to confirm this diagnosis, by further delineating two
lumens with distinct blood flow within the vessel.
Immediate Cardiothoracic Surgical consultation should be
obtained with suspicion of an ascending aortic dissection in
an unstable patient.

82. (B) Obstruction of the Pipes: DVT
If a thromboembolic event is suspected as the
cause of shock, the next step should be an
assessment of the venous side of “the pipes.” Since
the majority of pulmonary emboli originate from
lower extremity DVTs, the examination is
concentrated on a limited compression evaluation
of specific areas of the leg
Simple compression ultrasonography, which uses a
high frequency linear probe to apply direct pressure
to the vein, has good overall sensitivity for
detection of DVT

84. ECHO IN PEA
• Perform ECHO during “quick look” and
in pulse checks
• Change management based on
“positive” findings
• Pericardial tamponade
• Pericardiocentesis
• Hyperdynamic cardiacwall motion
• Volume resuscitate

85. ECHO IN PEA
• RV dilatation
• Hypoxic?? – Likely PE
• ECG – IMI with RV infarct?
• Profound hypokinesis
• Inotropic support
• Asystole
• Follow ACLS protocols
• Early data suggesting poor
prognosis

86. ECHO IN PEA
• False positive cardiac motion
• Transthoracic pacemaker
• Positive pressure ventilation

87. Echocardiography in chest trauma
► Rupture of cardiac structures(valves and
myocardium).
► Myocardial contusions (RWMA).
► Pericardial effusion.
► Aortic rupture or intimal tear.
► Rupture coronary sinus of valsalva.

88. PENETRATING CHEST TRAUMA

89. 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

90. Acute coronary syndrome
Echo in the assessment of complications
• Haemodynamic states
Globally reduced LV contractility
Right ventricular infarction
•Mechanical Complications
- Papillary muscle rupture
-Ventricular septal rupture
-Free wall rupture and tamponade
•Other
- Left ventricular aneurysm
- Mural thrombus
Hypovolumea
Ischemic MR

93. VENTRICULAR SEPTAL RUPTURE

94. FREE WALL RUPTURE