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Emergency Cardiac

Ultrasound
Phillip D. Levy, MD, MPH, FACEP
Assistant Professor of Emergency Medicine
Wayne State University, Detroit Receiving Hospital
Introduction
• “Stethoscope of the future”
• Rapid visualization of cardiac
structures and potential pathology
• More sensitive and specific than
physical exam, ECG or CXR
Primary Indications
• Suspected pericardial effusion or
tamponade
• Cardiac arrest
– PEA
– Asystole vs. fine ventricular fibrillation
• Acute hypotension
• Thoraco-abdominal trauma
Secondary Indications
• Acute chest pain
– Myocardial infarction
– Pulmonary embolism
– Aortic dissection
• Procedural guidance
– Pericardiocentesis
– Detection of transcutaneous pacer
capture
– Placement of transvenous pacer
Primary Clinical Concerns
• Is there cardiac activity ?

• Is there an effusion ?
Anatomical Overview
• Right ventricle anterior, left
posterior
• Lungs provide poor transit medium
– Air = scatter
– Use liver as acoustic window for
subxyphoid approach
• Images quality can be limited by bony
thorax
From: Yale Center for Advanced Instructional Media, Yale University. 2000
Technique
• Probe selection important
– Curved array: better contrast resolution
– Phased array (sector): less rib shadowing
• Average frequency = 3.5 MHz
– 2.5 MHz for larger patients
– 5.0 MHz for smaller patients
• Decrease depth and dynamic range
• Reverse screen for true cardiac
imaging
Normal Appearance
• Pericardium: uniform, brightly
echogenic line
• Myocardium: bulky, heterogeneous,
hyperechoic material
• Chambers: anechoic
Basic Image Planes
Subcostal
• Most useful overall
• Standard view in FAST exam
• Ideal for detection of effusion and
cardiac motion
• Diagonal view of heart
• Liver functions as acoustic window
Subcostal
• Probe marker to
patient’s right
• Subxyphoid position
• Shallow angle (~ 15°)
• Aimed at left shoulder
From: Yale Center for Advanced Instructional Media, Yale University. 2000
Subcostal
Parasternal Views
• Probe placed in left parasternal
region at 2nd to 4th intercostal space
– Left lateral decubitus position improves
images
• Long axis (right shoulder to left hip)
• Short axis (left shoulder to right hip)
• Enables differentiation between
pericardial and pleural effusions
Short axis Long axis
From: Gray, H. Anatomy of the Human Body 20th ed. 2000
Parasternal Long Axis
• Clearly displays
– Posterior wall of LV
– Free wall of RV
– Mitral and aortic
valves
– Proximal ascending
aorta

• Probe marker faces


left hip
From: Yale Center for Advanced Instructional Media, Yale University. 2000
Parasternal Long Axis
Parasternal Short Axis
• Cross-sectional view
through ventricles

• Rotate probe 90°


toward right hip
• Tilting probe
cephalad to caudad
allows imaging from
aortic valve to apex
Parasternal Short Axis

From: Yale Center for Advanced Instructional Media, Yale University. 2000
From: Yale Center for Advanced Instructional Media, Yale University. 2000
From: Yale Center for Advanced Instructional Media, Yale University. 2000
Parasternal Short Axis
Apical Views
• Left lateral decubitus position
• Probe at apex (4th or 5th intercostal
space) facing right shoulder
• More difficult to obtain
• Provides good images of chamber
dimensions
Apical 4-chamber
• Good for evaluation
of
– Wall motion
– Masses or clots

• Probe marker
toward right hip
From: Yale Center for Advanced Instructional Media, Yale University. 2000
Apical 4-chamber
Apical 2-chamber
• Less commonly used
in ED setting
• Shows anterior and
inferior walls
simultaneously

• Rotate probe 90°


– Marker faces
anterior and
cephalad
From: Yale Center for Advanced Instructional Media, Yale University. 2000
Apical 2-chamber
Functional Assessment
• Observation of dynamic changes of
cardiac cycle
• Estimation of ejection fraction
• Evaluation of wall motion
abnormalities
– Characterized as global or segmental
– Hypokinesis: reduced movement
– Akinesis: absent movement
– Dyskinesia: paradoxical movement
Normal Cardiac Cycle
Cardiac Measurements
• Chamber diameter
– Measured at right angle to long axis in
both systolic and diastolic phases
– Provide some functional information
– Most useful as indication of ventricular
strain
• Wall thickness
– Determination of hypertrophy
Clinical Indications
Pericardial Effusion
• High degree of accuracy for EP’s 1

– Sensitivity 99.9%
– Specificity 98.1 %
• Anechoic stripe between visceral and
parietal pericardium
– May be echogenic if malignant or
coagulated
• Usually surrounds heart completely
– If anterior only, likely pericardial fat
1
Plummer D, et al. Abstract, SAEM Scientific Assembly 1995.
Pericardial Effusion
• Cardiac impairment dependent of rate
of accumulation of fluid in pericardial
space, not amount
– Up to 50 cc may be physiologic; usually
not visible
– Small collection < 1 cm thick
– Large collections 1-2 cm thick
• Heart may swing freely with large
effusions
Pericardial Effusion
Pericardial Fat
Pericardial Blood Clot
Tamponade
• Cardiac compromise from effusion
• Beck’s triad seen in only 30 % 1
• Pulsus paridoxus late, non-specific
• Ultrasound findings
– Systolic right atrial collapse
– Diastolic right ventricular collapse
– Equalization of ventricular pressures
– Increased central venous pressure

1
Guberman BA, et al. Circulation 1981
Tamponade
• Respiratory variance in IVC can be
used to estimate central venous
pressure 1

IVC size Resp change RA pressure


< 1.5 cm Total collapse 0-5 cm/H20
1.5-2.5 > 50 % collapse 5-10
1.5-2.5 < 50 % collapse 11-15
>2.5 < 50 % collapse 16-20
>2.5 No change > 20
1
Ma, OJ and Mateer JR. Emergency Ultrasound, p 111. 2003
Effusion with Normal
Dynamic Function
Tamponade with RV
Collapse
Acute Hypotension
• Determination of etiology may allow
rapid intervention
• Tamponade
• Cardiogenic shock
– Global hypokinesis
– Left ventricular distention (MI)
– Right ventricular distention
• PE or RV infarct
Acute Hypotension
• Hypovolemic shock
– Hyperdynamic cardiac activity
– Small right chambers
– Collapsed IVC
• Septic shock
– Hyperdynamic activity
Cardiac Arrest Applications
• Can be used while CPR is in progress
• Evaluate for cardiac activity
• Treatment guidance for PEA
– Rule out tamponade
– Dynamism of cardiac contraction
• Hyperdynamic may indicate hypovolemia
• Hypodynamic may be ischemia or PE
• Assess capture by transthoracic
pacemaker 1
1
Ettin D, et al. JEM 1999
Blunt Thoracic Trauma
• Pericardial effusion
• Traumatic aortic rupture
– Not ideal diagnostic modality (CT or TEE)
– Look for
• Hematoma
• Intimal flaps
• Changes in vessel contour
• Sternal or rib fractures
– Associated with underlying cardiac injury
Blunt Thoracic Trauma
• Cardiac contusion
– Majority (73%) have signs of trauma 1
– Rarely associated with long-term
impairment 2
– Limited diagnostic value of formal echo 3
– Screening ED ultrasound sufficient to rule
out severe underlying injury 4
• Assess for wall motion abnormalities and RV
hypokinesis Snow, et al. Surgery 1982
1

2
Sturaitis M, et al.. Arch Intern Med 1986
3
Maenza RL, et al. Am J Emerg Med 1996
4
Welch RD. Emerg Med Clin North Am 2001
Penetrating Thoracic
Trauma
• Goal is early detection of pericardial
effusion BEFORE clinical signs
develop
• Hemopericardium is anechoic initially
– Echogenicity develops as blood
coagulates
• Imaging may be limited
– Subcutaneous emphysema
– Pneumopericadium
– Mechanical ventilation
Penetrating Thoracic
Trauma
• Study of utilization in 261 pts 1

– Sensitivity 100%, specificity 96.9%


– PPV 81%, NPV 100%
– Time to OR 12.1 +/- 5.9 min
• Comparison of outcomes 2

– 28 pts with ED cardiac ultrasound, 21


without
– Survival: 100% in echo, 57.1% in non-echo
– Time to diagnosis
• 15 min echo, 42 min non-echo 1
Rozycki GS, et al. J Trauma 1999
2
Plummer D et al. Ann Emerg Med 1992
Myocardial Infarct
• Determined by appearance of wall
motion abnormalities
– Poor sensitivity 1,2
– Better specificity, but difficult to
assess age of pathology 3,4
• ED cardiac ultrasound may be most
useful in ruling out other potential
diagnoses 1
Levitt MA, et al. Ann Emerg Med 1996
2
Muttreja M. Echocardiography 1999
3
Horowitz RS, et al. Circulation 1982
4
Sabia P, et al. Circulation 1991
Pulmonary Embolism
• Large PE may cause sonographically
identifiable right heart strain
• Wide range in accuracy 1-4
– Sensitivity 50-93%
– Specificity 81-98%
• Right heart strain: potential criteria
for thrombolytic administration? 5
1
Kasper W, et al. Am Heart J 1986
2
Nazeryollas P, et al. Eur Heart J 1996
3
Perrier A, et al. Int J Cardiol 1998
4
Rudoni R, et al. J Emerg Med 2001
5
Konstantinides S, et al. NEJM 2002
PE - Sonographic Findings
• Right ventricular dilation
– Parasternal long axis view
– Normal diameter 21±1 mm
– Abnormal > 25-30 mm
• Septal deviation to left ventricle
– Apical 4-chamber view
• Tricuspid regurgitation
• Right ventricle hypokinesis, with wall
thinning
Massive Pulmonary Embolism

From: Goldhaber, SZ. NEJM 2002


Resolution After
Thrombolytics

From: Goldhaber, SZ. NEJM 2002


Aortic Dissection
• Difficult to detect by transthoracic
echocardiogram
– Best seen on parasternal long axis view
• Appears as echogenic, mobile, linear
flap within aorta lumen
• May visualize double lumen
Other Findings
• Atrial myxoma
– Globular and echogenic, adherent to wall
• Mural thrombi
– Varying echogenicity
• Valvular vegetations
– Echogenic with irregular appearance
• Valvular dysfunction
– Best seen with color flow Doppler
Atrial Myxoma
Mural Thrombus
Bacterial Endocarditis
Procedural Applications
• Pericardiocentesis
– Left parasternal approach or entry into
largest area of fluid collection adjacent
to the chest wall
– Lower risk of cardiac or hepatic injury
• Transvenous pacing
– Allows highly accurate placement of
pacing wire 1

1
Aguilera P, et al. Ann Emerg Med 2000
Pericardiocentesis
Cardiac Ultrasound Pitfalls
• Not optimizing gain, depth and
dynamic range
• Settling for inferior images due to
technical difficulty
• Improper probe positioning
• Mistaking pericardial fat for effusion
• Mistaking clotted blood for normal
anatomy
Case 1
• 77 yo female with hx of breast CA, in
remission for 2 yrs, presents with
gradually worsening SOB and CP
• BP 90/50 HR 100 RR 26 T 99 SpO2 82 %
• Lungs with faint crackles, heart sounds
distant
• Abd exam nl; ext 2 + edema; neuro nl

• Management ?
Case 2
• 22 yo old male, with stab wound to
left chest, vital signs stable in field
• Loses consciousness of arrival in ED
• BP 60/palp HR 130 RR 6 T 98 SpO2 80%
• 2 cm stab wound over L 4th intercostal
space; no other injury
• Shallow breaths, no audible heart sounds

• Management ?
Take Home Points
• Learn the skill but know your
limitations !
• Be sure to observe dynamic function
• Tilt, rotate or angulate probe to
obtain optimal images
• Use early, use often!

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