Download - Echocardiography in cardiac emergency
Role of TTE
Dr.Ayman AbdelazizAssisstant Prof. of Cardiology Mansoura UniversityEchocardiography in Emergency
Clinical indication1- Hemodynamic instability and/or hypoxemia of unclear aetiolog (i) Suspected tamponade (ii) Pulseless electrical activity (PEA) can be the presenting symptom for: Tamponade Massive pulmonary embolism Acute massive internal hemorrhage Tension pneumothorax2- Aortic dissection 3- Acute coronary syndromes4- Acute valvular pathology, Prosthetic valve malfunction5- Infective endocarditis 6- Massive Pulmonary embolism7- Acute embolic event8- 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.
Echo AlgorithmUnstable patient with shock or pulmonary oedema
Quick targeted Echo (minimum views subcostal , Apical)moderate pericardial effusion Compressed RA/RVCollapsed IVC
Severely enlarged akinetic RV Severe hypokinetic LVSmall hyperdynamic heart Collapsed IVCAssume tamponade
Assume pulmonary embolism
Assume acute pump failure MIMyocarditis)
Assume severe hypovolemia Major internal bleedingSepsis
Pericardial Tamponade
EUROECHO CONGRESS - COPENHAGEN -TEACHING COURSE 2010RV and RA collapse Without thesecollapsescardiactamponade isunlikely
DiagnosisEchocardiogram (tamponade is clinical diagnosis)Pericardial effusionEarly diastolic collapse of the right ventricular free wallLate diastolic compression/collapse of the right atriumSwinging of the heart in its sacRespiratory variation of mitral and tricuspid flowDilated IVC (collapse < 50%)
Respiratory variation of the mitral flow
Echo Guided- PericardiocentesisSubcostal approachTraditional approachBlindIncreased risk of injury to liver, heartEcho guidedLeft parasternal preferred for needle entry orLargest area of fluid collection adjacent to the chest wall
Pulmonary Embolism
Echocardiography in PE: to identify RV overload
RV dilatation.Abnormal right ventricular wall motion. (McConnells sign)Systolic flattening of the interventricular septum.Tricuspid valve insufficiencyIncreased pulmonary arterial pressureInferior vena cava congestionDilated pulmonary arteryRight-sided cardiac thrombus.
Hypotension
Abnormal findingsIs the cause of hypotension cardiac in etiology?Is it due to a pericardial effusion?Is is due to pump failure?
Unexplained HypotensionCardiogenic shock Poor LV contractilityHypovolemiaHyperdynamic ventriculesRight ventricular infarct/large pulmonary embolismMarked RV dilitation/hypokinesisTamponadeRV diastolic collapse
22
Cardiogenic shockDilated left ventricle
Hypocontractile walls
23Chf avi
Small hyperdynamic heartE/A < 1Small (< 20mm) IVC with exaggerated collapse with deep inspiration
Hypovolemia
24
Non Traumatic Resuscitation
Direct VisualizationIs there effective myocardial contractility?AsystoleHypokinesisNormalIs there a pericardial effusion?
ECHO in PEAPerform ECHO during quick look and in pulse checksChange management based on positive findingsPericardial tamponadePericardiocentesisHyperdynamic cardiac wall motionVolume resuscitate
ECHO in PEARV dilatationHypoxic?? Likely PEECG IMI with RV infarct?Profound hypokinesisInotropic supportAsystoleFollow ACLS protocols Early data suggesting poor prognosis
ECHO in PEAFalse positive cardiac motionTransthoracic pacemakerPositive pressure ventilation
Penetrating Chest Trauma
Penetrating Cardiac TraumaPhysicians ability to determine whether there is a hemodynamically significant effusion is poorBecks Triad Dependent on patient cardiovascular statusFindings are often lateDeterminants of hemodynamic compromiseSize of the effusionRate of formation
Acute coronary syndromeEcho in the assessment of complications
Complication of AMIHaemodynamic states Globally reduced LV contractility Hypovolumea Right ventricular infarction Ischemic MRMechanical Complications - Papillary muscle rupture - Ventricular septal rupture - Free wall rupture and tamponadeOther - Left ventricular aneurysm - Mural thrombus
Levine, R. A. N Engl J Med 2004;351:1681-1684Ischaemic mitral regurgitationEUROECHO CONGRESSCOPENHAGENTEACHING COURSE 2010
Ischemic Mitral Regurgitation
Aortic dissection
2AorticDissectionIHPU
Echo Algorithm
Role of TEEAdvantages: Ideal Dx test for AASSafeFastBedside exam or in OR w/o transportIdentifies extent and etiology of injury and associated complicationsSensitive (94-100%) and specific (77-100%)Disadvantages:InvasiveSedationTEE blindspot -- trachea between esophagus and upper ascending aorta
True vs. False Lumen
True vs. False Lumen
17TEE. Additional informationI- Entry tear location and size
Prosthetic valve thrombosis
Prosthetic valve thrombosisRisk factorsInadequate oral anticoagulantInterruption of oral anticoagulation (non cardiac surgery, pregnancy)Prosthetic type: Starr Edwards AFLow EF < 35%LA > 5cmSpontanous echo contrastMVR, TVR
Echo
1. To assess hemodynamic severity
TTE and Doppler echo
2. To assess valve motion and clot burden
TEE and/or fluoroscopy
ECHOCARDIOGRAPHIC SIGNS OFOBSTRUCTIVE PVT
Reduced valve mobilityPresence of thrombusAbnormal transprosthetic flowCentral prosthetic regurgitationElevated transprosthetic gradientsReduced prosthetic area
Dehiscence
Thank you