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BEDSIDE CARDIAC ULTRASOUND

Martine Sargent, MD Ultrasound Director, San Francisco General Hospital

Assistant Clinical Professor UCSF Department of Emergency Medicine

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Overview

• Why, Who, What, How of ED Ultrasound...

• How to of Focused Cardiac Examination

• Difficulties & Troubleshooting

• Cases demonstrating pathology

• Literature (briefly!)

Why? - Indications

• Unexplained Dyspnea

• Chest Trauma

• Chest Pain

• Cardiac Arrest

• Unexplained Hypotension

• Procedures

ACEP. Emergency Ultrasound Imaging Criteria Compendium. Ann Em Med. 2006. Oct 49(4): 487-510.

Who? - ED Physicians

• Limited Examination - yes/no questions

• Integrated Bedside Assessment

• Code Management

• Facilitate Interventions/Procedures

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What? - to look for • Pericardial Fluid

• Pericardial Tamponade

• Global Cardiac Function

• Cardiac Activity

• Hyperdynamic/Hypovolemia

• Needle location, capture, success

How? - �Technique

Probe Selection: -Microconvex or phased array probe -3-5 MHz probe Cardiac Setting

How? - Cardiac Views

1. Subxiphoid/Subcostal

2. Parasternal Long Axis

3. Parasternal Short Axis

4. Apical Four Chamber

1

3 2

4

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How? - Cardiac Views

• Subxiphoid/Subcostal

• Parasternal Long Axis

• Parasternal Short Axis

• Apical Four Chamber

2

1

1

3

4

3

2

4

Exam

• Subxyphoid

• Parasternal long axis

• Parasternal short axis

• Apical 4 chamber view

Educational media courtesy of Mobile Medical Media and the SonoSite Corporation

Subxiphoid

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Subxiphoid

Subxiphoid

• “FAST” view

• Probe under ribs

• Indicator to pt RIGHT shoulder

• Use liver as acoustic window

RV

LV RA

LA

Liver

Text

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TOO SHALLOW GASTRIC BUBBLE

Parasternal Long

Parasternal long

LV

RV

RV

LVOT

LA MV

AV

MV

AV

Chordae

Papillae

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Parasternal Long Axis

• Probe at Left Sternal Border

• 3rd - 5th intercostal space

• Indicator to RIGHT shoulder

• Long axis view of heart

LV

RV Mitral Valve Aortic Valve

Ao

Pericardium

Text

Parasternal Long

• PS views best for estimating EF

• Visualize mitral & aortic valves

Mark D, Ku B, Dean A, et. al. Directed bedside transthoracic echocardiography: preferred cardiac window for left ventricular ejection fraction estimation in critically ill patients. Am J. Emerg Med 2007; 25, 894-900.

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Parasternal Short

PSSA

Parasternal Short

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Parasternal Short Axis

• Left sternal border

• 90o counterclockwise to Long Axis view

• Indicator to RIGHT HIP

• PS views best for estimating LVEF

• Text LV

RV Septum

PSSA - aortic valve

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PSSA - Aortic Valve

• Aortic valve near base

• Mitral valve at annulus

• LV toward apex

Apical 4 approach

3D image courtesy of Yale

At PMI 5th ICS

under nipple marker R

Apical 4 chamber

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Apical 4 • From Apex to

the base

• Visualizes all 4 chambers side-by-side

• relative chamber size

• Best septal view

LV

RV

RA LA

Text

Troubleshooting

•  Pulmonary Hyperinflation - COPD, Ventilation

•  Poor Parasternal windows

•  Favor Apical & Subxiphoid

• Obese, Pregnant, Abd Pain

•  Favor Parasternal windows

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CASE of Dyspnea

• 42 yo female presents to the ED with 2 weeks of increasing shortness of breath.

• Vital signs are BP 118/82, P 104, RR 24, T 37.6, SaO2 97%RA.

• CXR shows:

Text

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Pericardial Effusion

• Reduced time to diagnosis

• Suggested by CXR finding of enlarged cardaic silhouette

• Traumatic, Uremic, Malignant, Infectious

• Fake out of epicardial fat

• Ranges from benign to tamponade

Pericardial Effusion

• Dark stripe between pericardium & myocardium

• Dependent area more sensitive & specific

short-axis: effusion

• Doughnut Shaped

• Anechoic Stripe

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Mandavia et al. Ann Em Med (2001) 38(4) 377-382

short-axis: effusion Text

PITFALLS & fakeouts:

 Fakeouts of Pleural or Abdominal cavity fluid

 Fat will move together with heart

 Beware non-dependent collections  Beware of clotted blood/loculations  Myocardial reflections

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Case of Blunt Trauma

• 27 yo male BIB medics as trauma S/P running his car into a tree in a suicide attempt. Pt’s mental status deteriorates in the trauma bay and goes into PEA.

• Bedside ultrasound shows:

Pericardial Tamponade

Pericardial Tamponade

• Acute Chest Trauma

• Large Chronic Effusion

• Expanding Effusion

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Tamponade Systolic collapse of RA, Diastolic collapse RV

Penetrating Chest

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Standstill

Trauma Resucitation

• Yes/No - Cardiac Activity

• Yes/No - Effusion/Tamponade

• Reduce time to OR or intervention

CASE of chest pain

• 62 yo female presents to the ED with chest pain for 6 hours. She is becoming nauseous and diaphoretic.

• Vital signs are BP 89/46, HR 109, RR 16, T 36.9. CXR shows:

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Ejection Fraction

• 115 patients ED vs. Formal echo

• Poor <30%, Moderate 30-55%, Normal >55%

• Concordance 86%

3Randazzo M, Snoey E, et al. Accuracy of Emergency Physician Assessment of Left Ventricular Ejection Fraction and Central Venous Pressure Using Echocardiogram. Acad Emerg Med. 2003; 10: 973-977.

EF- Normal Text

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EF - LOW Text

Ejection Fraction

• Parasternal Short Axis View

• How well does the heart move?

Code Management • Yes/No - Cardiac Activity?

• Yes/No - Continue Resucitation?

• PEA, No motion = 100% PPV Death

• May Elucidate Reversible Causes

• Effusion/Tamponade

• Evidence of PE/RV collapse

•  2Blaivas M, Fox JC. Outcome in Cardiac Arrest Patients Found to Have Cardiac Standstill on the Bedside Emergency Department Echocardiogram. Acad Emerg Med. 2001; 8: 616-621.

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Text

PEA

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Standstill/Effusion�

Hypotension Management

• Is patient dry?

• Assess IVC for volume status

• Hyperdynamic heart may indicate hypovolemia, sepsis

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Finding IVC

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IVC - Normal

Plethora

CASE of Hypotension

• 36 yo male with h/o nephrotic syndrome presents to the ED with chest pain & SOB. He is anxious nauseous and diaphoretic.

• Vital signs are BP 92/60, HR 118, RR 28, T 36.9, O2 Sat 95%.

• CXR shows:

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Plethora Text

Text

Pulmonary Embolus

• PE & Shock = Thrombolytics

• Best view = Apical 4 chamber

• RV dilatation

• IVC Plethora

• Abnormal Septum

Text

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Interventions

• Pericardiocentesis

• Transvenous Pacer Insertion

• Trancutaneous & Transvenous Pacer Capture

Summary

• Why? Remember Clinical Indications

• Why? Case Management, Facilitate Interventions & Procedures

• Who? ED docs

• What? Yes/No Questions

• How? 4 Views

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Exam

• Subxyphoid

• Parasternal long axis

• Parasternal short axis

• Apical 4 chamber view

Educational media courtesy of Mobile Medical Media and the SonoSite Corporation

Questions Questions Questions Questions Questions Questions Questions Questions Questions Questions Questions ?

References •  ACEP. Emergency Ultrasound Imaging Criteria Compendium. Ann Em Med. 2006. Oct 49(4): 487-510.

•  Mark D, Ku B, Dean A, et. al. Directed bedside transthoracic echocardiography: preferred cardiac window for left ventricular ejection fraction estimation in critically ill patients. Am J. Emerg Med 2007; 25, 894-900.

•  Blaivas M, et al. Potential Errors in the Diagnosis of Pericardial Effusion on Trauma Ultrasound for Penetrating Injuries. 11/2000. 1261-1266.

•  Blaivas M, Fox JC. Outcome in Cardiac Arrest Patients Found to Have Cardiac Standstill on the Bedside Emergency Department Echocardiogram. Acad Emerg Med. 2001; 8: 616-621.

•  Randazzo M, Snoey E, et al. Accuracy of Emergency Physician Assessment of Left Ventricular Ejection Fraction and Central Venous Pressure Using Echocardiogram. Acad Emerg Med. 2003; 10: 973-977.

•  Salen P, Melnicker L, Chooljian C, Et.Al: Does the Presence or Absence of SIonographically Identified Cardiac Activity Predict Resucitation Outcomes of Cardiac Arrest Patients? Am J. Emerg Med 2005; V3: 459-462.

•  Sierzenski PR, et al. Emergency Physician Echocardiography Decreases Time to Diagnosis of Pericardial Effusions. Acad Emerg Med. 2003; 10: 561-562.

•  Tayal VS, Moore CL, Rose GA. Emergency Ultrasound. Chapter 5: Cardiac. Ma & Mateer. 2003. McGraw Hill.

•  Mandavia, et al. Bedside Echocardiography by Emergency Physician. Annals of EM; 10/2001;377-382