Download Echocardiography

11/11/11
Objectives
Point-of-Care
Echocardiography
Rimon Bengiamin, MD, RDMS
•  Discuss the goals of point-of-care cardiac
ultrasound
•  Review the cardiac anatomy
•  Explore strategies for image (window)
acquisition
•  Develop recognition of pathology on
images
•  Discuss integration of point
Why do echo in the
Emergency Department?
•  Faster!
•  Expedite care
•  Narrow the differential
•  Get much of the same information
In what capacity should
it be used?
•  Keep the exam straightforward
•  Evaluate for gross abnormalities and overall
cardiac function
obtained by invasive monitoring
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Primary Indications
•  Cardiac arrest
•  Pericardial Effusion
•  Massive PE
•  LV function
•  Unexplained hypotension
•  Estimation of CVP
Anatomy
Advanced Applications
•  Severe valvular dysfunction
•  Proximal aortic dissection
•  Myocardial ischemia
Flow
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Anatomy
Cardiac Probe
•  Small footprint
•  Deep penetration
•  2-4 MHz
•  Good for motion not clarity
Image/Probe
Orientation
I m confused!!!
•  Most confusing study in terms of
orientation
•  Based on standard echo views in cards
•  Usually when you set the machine to the
cardiac probe, it will flip the normal image
orientation. However, this isn t always
true.
•  Just learn the standard views and recognize
structures
Radiology
Cardiology
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I can t get images!!!
•  Difficult
•  Few sonographic windows because of
ribs, the sternum, and lungs in the way
•  Bone shadows
•  Lungs are air filled so they don t transmit
sonographic sound waves
Subxiphoid 4-chamber
The Standard Views
•  Subxiphoid
•  4-Chamber
•  Short Axis
•  Subcostal Long
Axis/IVC
•  Parasternal
•  Long Axis
•  Short Axis
•  Apical 4 chamber
•  Suprasternal
Subxiphoid 4-chamber
•  Most useful view in
emergency ultrasound
•  Can see:
•  Effusion
•  Chamber size and
function
•  Both AV valves
•  Similar to the
FAST view
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Subxiphoid 4-chamber
Subxiphoid Short-Axis
•  Similar to the parasternal
RA
short axis view
RV
•  Evaluate wall motion,
LV
mitral valve, and aortic
valve
•  Great in COPD patients
•  Rotate your probe 90
o
LA
Subxiphoid Short-Axis
counterclockwise from
the four-chamber view
Subxiphoid Short-Axis
LV
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Subxiphoid Long-Axis
•  Good for
Subcostal Long-Axis
evaluating the IVC
for volume status
and right-sided
heart pressures
•  Aim the probe dot
toward the
patient s feet
Subcostal Long-Axis
Parasternal Long-Axis
•  Ventricle function
Liver
and size
•  Mitral/aortic valve
•  Aortic outlet
RA
IVC
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Parasternal Long-Axis
Parasternal Long-Axis
RV
AoV
Ao
LV
Parasternal Short-Axis
MV
LA
Parasternal Short-Axis
•  LV wall motion
•  Mitral/aortic valve
function
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Parasternal Short-Axis
Parasternal Short-Axis
LA
LV
Apical 4-Chamber
•  Overall heart
function
•  Ventricle/atrial
chamber size
•  Wall motion
•  Valve function
•  Pericardial fluid
•  pressure gradients
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Apical 4-Chamber
Apical 4-Chamber
Septum
RV
LV
MV
TrV
RA
Suprasternal
LA
Suprasternal
•  Aortic arch,
brachiocephalic
artery, left
carotid and left
subclavian
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Suprasternal
Ao Arch
Ascending Ao
Clinical Indications
Right PA
Descending Ao
Cardiac Arrest/PEA
•  Palpation of pulses is unreliable
•  Studies showing that some patients with
pressures of 50-80 systolic did not have palpable
pulses (Mandavia et al). •  Examination of cardiac function with US during
codes can help assess patient prognosis
Cardiac Arrest/PEA
•  Ultrasound is most helpful in guiding/narrowing
the differential
•  Differential of PEA
•  5 H s - hypovolemia, hypoxia, acidosis
(hydrogen), hypo/hyperkalemia, hypoglycemia,
hypothermia
•  Those with contractility should undergo active
•  5 T s - tox, tamponade, pneumo (tension), MI
•  Those with cardiac standstill are unlikely to be
•  Ultrasound can pick up hypovolemia, MI, PE, and
resuscitation
revived (Salen et al). (thrombus) , PE (thrombus)
tamponade. 50% of your differential isn t bad!
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Cardiac Arrest
PEA
Pericardial Effusion
Pericardial Effusion
•  Plummer et al
•  100% sensitivity
•  decreased time to diagnosis from 42.4
minutes to 15.5 minutes •  increased survival from 57.1% to 100%
•  Variable, nonspecific presentation in the
setting of nontraumatic effusions
•  At risk include idiopathic/viral pericarditis,
HIV, hepatitis B, bacterial pericarditis,
fungal pericarditis, autoimmune processes,
Dressler syndrome, drug induced (INH,
cyclosporine), neoplastic, radiation, renal
failure, hypothyroid, etc, etc, etc.
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Pericardial Effusion
Pericardial Tamponade
•  Any patient with a pericardial effusion is at
risk for developing tamponade
•  Remember the starling curve
•  Slowly accumulating effusion gives the
pericardium time to stretch
•  A quickly accumulating effusion reaches a
critical point where cardiac function is
impaired ( last drop phenomenon)
Pericardial Tamponade
Pericardiocentesis
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Pericardial Clot
Massive Pulmonary
Embolism
•  70% of patients who die from PE die within the
first hour
•  Early thrombolytic therapy or embolectomy is
required
•  Don t wait for time-consuming imaging in unstable
patients
•  A combination of echo and DVT study can help
you determine whether or not to consider lytics
or call CT surgery
Massive Pulmonary
Embolism
Dilated RV
•  Findings
•  Massive right ventricular dilatation
•  Right sided heart failure
•  Small, vigorously contracting left ventricle
•  Know the patient s history
•  Some patients have chronic right heart strain
such as those with pulmonary hypertension
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Dilated RV
Undifferentiated
Hypotension
•  Broad differential for shock patients
•  Main goal is to narrow that differential
•  Is the patient euvolemic or hypovolemic?
•  Look at the IVC
•  Keep in mind other causes of hypotension
(tamponade, pneumo, PE, etc)
Undiffentiated
Hypotension
Distended IVC
•  IVC
•  Normal IVC diameter is 1.5-2.5 cm
•  Normal respiratory variation in size
•  Should collapse around 50% with deep
inspiration
•  Complete collapse = hypovolemia
•  No collapse = hypervolemia
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Myocardial Ischemia
•  Good for use as an extra diagnostic tool
•  Can help differentiate CHF from COPD in
Wall Motion
Abnormality
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chest pain patients
•  Look for left ventricular dysfunction
•  Look for large IVC
•  Look for wall motion abnormality
LV function
poor
normal
LV function
poor
normal
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Valvular Dysfunction
Mitral Stenosis
•  Ultrasound can be useful for evluation of
valvular dysfunction that results in critical
failure
•  Usually an incidental finding
•  Advanced
•  With time and studies you will start to
recognize abnormalities
Aortic Aneurysm/
Dissection
normal
abnormal
Aortic Aneurysm/Dissection
•  Look at the aortic root in the long axis
parasternal view
•  Look at the aortic arch by attempting the
suprasternal view
•  Normal aortic root is approx 3 cm
•  Look for a false lumen
Normal
Abnormal
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Aortic Dissection
Summary
•  Learn basic views
•  Start with subxiphoid and paraternal
•  Try to produce standard images
•  Always use the same method
•  Practice on normal patients
•  Abnormalities may be obvious
False Lumen
Questions
?
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