Focused Cardiac Ultrasound

Emergency Physician at Jen-Ai Hospital Dali
Apr. 26, 2016

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Focused Cardiac Ultrasound

  1. Image-Based Resuscitation of the Hypotensive Patient with Cardiac Ultrasound: An Evidence-Based Review J Trauma Acute Care Surg. 2016;80:511-518.
  2. Point-of-care cardiac ultrasound does not require advanced technology. It can be performed with a simple 2D ultrasound machine. It is performed at the bedside by any treating clinician, emergency physicians, residents, paramedics, and even medical students. International guidelines that suggest term Focused Cardiac Ultrasound (FoCUS) should be a core competency among all critical care providers.
  3. The diagnostic targets of this simplified examination are gross cardiac contractility and anatomy (LV and RV size and function) as well as volume status and presence of a pericardial effusion ± tamponade.
  4. Summary of the Terminology Used to Describe Point-of-Care Cardiac Ultrasound Undifferentiated hypotensive patient protocol. 2001, Rose Focused assessment with trans-thoracic echocardiography, 2004, Jensen Bedside limited echocardiography by the emergency physician. 2004, Pershad Goal-directed transthoracic echocardiography. 2005, Manasia Focused echocardiographic evaluation in resuscitation. 2007, Breitkreutz Goal-oriented hand-held echocardiography. 2007, Vignon Cardiovascular limited ultrasound examination. 2007, Kimura Focused critical care ultrasound study. 2007 Beaulieu Rapid assessment with cardiac echocardiography. 2007, Seppelt Intensivist bedside ultrasound. 2007, Carr Bedside echocardiographic assessment in trauma. 2008 Gunst Focused cardiovascular ultrasound. 2009, Cowie Focused intensive care echocardiography. 2009, Fletcher Abdominal and cardiac examination with sonography in shock. 2009, Atkinson Focused echocardiographic evaluation in life support. 2010, Breitkreutz Rapid ultrasound in shock. 2010, Perera Focused rapid echocardiographic examination. 2011, Ferrada Limited transthoracic echocardiography. 2011, Ferrada Goal-directed echocardiography. 2012, Schmidt
  5. Technique M mode: to examine structures that are in motion such as the cardiac walls or the walls of the vena cava 1. Subcostal long axis (SLAX) 2. Subcostal inferior vena cava (SIVC) 3. Parasternal long axis (PLAX) 4. Parasternal short axis (PSAX) 5. Apical 4 chamber (A4CH)
  6. SLAX and SIVC views FAST
  7. PLAX and PSAX left lateral decubitus position LV LVOT RV RV LV
  8. A4CH left lateral decubitus position supine position RA LA RV LV
  9. Clinical Application Differentiate between different types of shock Determine the need and the quantity of fluid or resuscitation required in hypotensive patients
  10. Volume Status Diagnostic of hypovolemia in hypotensive patients: empty heart or flat IVC In hypovolemia, the ventricular walls will come together or ‘‘kiss,’’ or in cardiologist lingo, an ejection fraction >70% Flat IVC: IVC collapses >50% during the respiratory cycle
  11. The Significance of the IVC in Volume Status The overall size of the vessel is not as important as the variability. Increasing the intra-thoracic pressure would result on an increased IVC size but might not change the variability. A small IVC on a hypotensive ventilated patient is diagnostic of hypovolemia, but a full IVC does not rule out this diagnosis.
  12. 1. Subxiphoid; 2. Middle clavicular line; 3. Midaxillary line.
  13. GLOBAL HEART FUNCTION AND VENTRICULAR SIZE Visual estimations of cardiac function are equivalent to more detailed measurements, decreased LV function can be diagnosed by novice providers with minimal training. For the non-cardiologist, one only needs to be able to detect if there is a decrease in global cardiac activity.
  14. The American Society of Echocardiography current recommendation to assess LV function on the short-axis view at the level of the mitral valve. Assessment of global cardiac function: – the inward motion of the endocardium – the presence of thickening of the myocardium – the longitudinal motion of the mitral annulus – the overall geometry of the ventricle
  15. In hypotensive patients, evaluation of the function and the size of the RV can be very useful in diagnosis and treatment for pulmonary embolism. RV enlargement in the presence of a massive pulmonary embolus is predictive of poor outcome.
  16. Pericardial Effusion FAST: subcostal view Cardiac tamponade: right heart compression
  17. Lung and Pleura Ultrasound in the Deteriorating Patient A lines are horizontal, regularly spaced hyper-echogenic lines representing reverberations of the pleural line. These are motionless and are artifacts of repetition. B lines are vertical narrow lines arising from the pleural line to the edge of the ultrasound screen. ‘‘comet tails ’’
  18. Assessing pulmonary interstitial fluid allows clinicians to recognize a cardiogenic cause of respiratory failure. When evaluating for fluid status, predominance of B lines should discourage the clinician for further fluid resuscitating since it is indicative of interstitial lung edema.
  19. Pneumothorax: absence of ‘‘lung sliding.’’ The lung point: an interface between normal lung and pneumothorax. Hemothorax is identified in the lateral position and sometimes in the FAST.
  20. Q & A