1. Cardiac Ultrasound in Emergency Medicine
Anthony J. Weekes MD, RDMS
Sarah A. Stahmer MD
For the SAEM US Interest Group

2. Primary Indications Thoraco-abdominal trauma
Pulseless Electrical Activity
Unexplained hypotension
Suspicion of pericardial effusion/tamponade

3. Secondary Indications
Acute Cardiac Ischemia
Pericardiocentesis
External pacer capture
Transvenous pacer placement

4. Main Clinical Questions
What is the overall cardiac wall motion?
Is there a pericardial effusion?

5. Cardiac probe selection
Small round footprint for scan between ribs
2.5 MHz: above average sized patient
3.5 MHz: average sized patient
5.0 MHz: below average sized patient or child

6. Main cardiac views
Parasternal
Subcostal
Apical

7. Wall Motion Normal Hyperkinetic Akinetic
Dyskinetic: may fail to contract, bulges outward at systole
Hypokinetic

8. Orientation Subcostal or subxiphoid view
Best all around imaging window
Good for identification of:
Circumferential pericardial effusion
Overall wall motion
Easy to obtain – liver is the acoustic window\

9. Subcostal View Most practical in trauma setting
Away from airway and neck/chest procedures

10. Subcostal View Liver as acoustic window
Alternative to apical 4 chamber view

11. Subcostal View

12. Subcostal View

13. Subcostal View Angle probe right to see IVC
Response of IVC to sniff indicates central venous pressure
No collapse
Tamponade
CHF PE
Pneumothorax

14. Parasternal Views Next best imaging window Good for imaging LV
Comparing chamber sizes
Localized effusions
Differentiating pericardial from pleural effusions

15. Parasternal Long Axis Near sternum 3rd or 4th left intercostal space
Marker pointed to patient’s right shoulder (or left hip if screen is not reversed for cardiac imaging)
Rotate enough to elongate cardiac chambers

16. Parasternal Long Axis

17. Parasternal Long Axis View

18. Parasternal Short Axis
Obtained by 90° clockwise rotation of the probe towards the left shoulder (or right hip)
Sweep the beam from the base of the heart to the apex for different cross sectional views

19. Parasternal Short Axis View

20. Parasternal Short Axis

21. Apical View Difficult view to obtain
Allows comparison of ventricular chamber size
Good window to assess septal/wall motion abnormalities

22. Apical Views Patient in left lateral decubitus position
Probe placed at PMI
Probe marker at 6 o’clock (or right shoulder)
4 chamber view

23. Apical 4 chamber view Marker pointed to the floor
Similar to parasternal view but apex well visualized
Angle beam superiorly for 5 chamber view

24. Apical 4 chamber view

25. Apical 2 chamber view Patient in left lateral decubitus position
Probe placed at PMI
Probe marker at 3 o’clock
2 chamber view

26. Apical 2 chamber view
Good look at inferior and anterior walls

27. Apical 2 chamber view From apical 4, rotate probe 90° counterclockwise
Good view for long view of left sided chambers and mitral valve

28. Abnormal findings
Pericardial Effusion

29. Case Presentation
45 year old male presents with SOB and dizziness for 2 days. He has a long smoking history, and has complained of a non-productive cough for “weeks”
Initial VS are BP 88/palp, HR 140
PE: Neck veins are distended
Chest: Clear, muffled heart sounds
Bedside sonography was performed

31. Echo free space around the heart
Pericardial effusion
Pleural effusion
Epicardial fat (posterior and/or anterior)
Less common causes:
Aortic aneurysm
Pericardial cyst
Dilated pulmonary artery

32. Size of the Pericardial Effusion
Not Precise
Small: confined to posterior space, < 0.5cm
Moderate: anterior and posterior, 0.5-2cm (diastole)
Large: > 2cm

33. Pericardial Fluid: Subcostal

34. Clinical features of Pericardial effusion
Pericardial fluid accumulation may be clinically silent
Symptoms are due to:
mechanical compression of adjacent structures
Increased intrapericardial pressure

35. Pericardial Effusion:Asymptomatic
Up to 40% of pregnant women
Chronic hemodialysis patients
one study showed 11% incidence of pericardial effusion
AIDS
CHF
Hypoproteinemic states

36. Symptoms of Pericardial Effusion
Chest discomfort (most common)
Large effusions:
Dyspnea
Cough
Fatigue
Hiccups
Hoarseness
Nausea and abdominal fullness

37. Cardiac Tamponade Increased intracardiac pressures
Limitation of ventricular diastolic filling
Reduction of stroke volume and cardiac output

38. Ventricular collapse in diastole

39. Tamponade
Perefftamponade

40. Hypotension

41. Abnormal findings Is the cause of hypotension cardiac in etiology?
Is it due to a pericardial effusion?
Is is due to pump failure?

42. Unexplained Hypotension
Cardiogenic shock
Poor LV contractility
Hypovolemia
Hyperdynamic ventricules
Right ventricular infarct/large pulmonary embolism
Marked RV dilitation/hypokinesis
Tamponade
RV diastolic collapse

43. Cardiogenic shock
Dilated left ventricle
Hypocontractile walls
Chf avi

44. Hypovolemia Small chamber filling size Aggressive wall motion
Flat IVC or exaggerated collapse with deep inspiration

45. Massive PE or RV infarct
Dilated Right ventricle
RV hypokinesis
Normal Left ventricle function
Stiff IVC

46. Case presentation ? overdose
27 yo f brought in with “passing out” after night of heavy drinking.
Complaining of inability to breathe!
PE: Obese f BP 88/60 HR 123 Ox 78%
Chest: clear
Ext: No edema
Bedside sonography was performed

47. PE

49. Chest pain then code
55 yo male suffered witnessed Vfib arrest in the ED
ALS protocol - restoration of perfusing rhythm
Persistant hypotension
ED ECHO was performed

52. R sided leads

53. Non Traumatic Resuscitation

54. Direct Visualization Is there effective myocardial contractility?
Asystole
Myocardial “twitch”
Hypokinesis
Normal
Is there a pericardial effusion?

55. ECHO in PEA Perform ECHO during “quick look” and in pulse checks
Change management based on “positive” findings
Pericardial tamponade
Pericardiocentesis
Hyperdynamic cardiac wall motion
Volume resuscitate

56. ECHO in PEA RV dilatation Profound hypokinesis Asystole
Hypoxic?? – Likely PE
ECG – IMI with RV infarct?
Profound hypokinesis
Inotropic support
Asystole
Follow ACLS protocols (for now)
Early data suggesting poor prognosis

57. ECHO in PEA False positive cardiac motion Transthoracic pacemaker
Positive pressure ventilation

58. Case presentation Morbidly obese female with severe asthma
Intubated for respiratory failure
Subcutaneous emphysema developed
Bilateral chest tubes placed
Persistent hypotension at 90/palp
Dependent mottling noted
ECHO was performed

59. Ineffective cardiac contractions

60. Optimizing Performance
Assessing capture by transthoracic pacemaker
Pericardiocentesis
Transvenous pacemaker placement

61. Optimizing Performance
Assessment of capture by transthoracic pacemaker
Ettin D et al: Using ultrasound to determine external pacer capture JEM 1999

62. Case Presentation
70 yo f collapsed in lobby. She was brought into the ED apneic, hypotensive. She was quickly intubated and volume resuscitation begun.
VS: BP 80/50 HR 50 Afebrile
Physical exam : Thin, minimally responsive f. Clear lungs, nl heart sounds, abdomen slightly distended with decreased bowel sounds. No HSM, ? Pelvic mass
ECG: SB, LVH, no active ischemia

63. Clinical questions? Why is she hypotensive? Volume loss Pump failure
?Ruptured AAA
Pump failure
Bedside sonography was performed while we were waiting for the “labs”

64. Increase HR with PM “on”

65. What did this tell us? Normal wall motion
No pericardial/pleural effusion
Good capture with the transthoracic PM

66. Asystole w/ Transthoracic PM
Asystole epm.avi

67. Optimizing performance
Pericardiocentesis
Standard of care by cardiology/CT surgery to use ECHO to guide aspiration

68. US Guided- Pericardiocentesis
Subcostal approach
Traditional approach
Blind
Increased risk of injury to liver, heart
Echo guided
Left parasternal preferred for needle entry or…
Largest area of fluid collection adjacent to the chest wall

69. Large pericardial effusion

70. Technique

71. Optimizing performance
Placement of transvenous pacemaker
Aguilera P et al: Emergency transvenous cardiac pacing placement using ultrasound guidance. Ann Emerg Med 2000

72. Untimely end 30 yo brought in after he “fell out”
Ashen m with no spontaneous respirations
VS: No pulse, agonal rhythm on monitor
Intubated/CPR
Transvenous pacemaker placed, no capture.
ECHO showed

73. PM placement

74. Penetrating Chest Trauma

75. Penetrating Cardiac Trauma
Physician’s ability to determine whether there is a hemodynamically significant effusion is poor
Beck’s Triad
Dependent on patient cardiovascular status
Findings are often late
Determinants of hemodynamic compromise
Size of the effusion
Rate of formation

76. Penetrating Cardiac Injury
Emergency department echocardiography improves outcome in penetrating cardiac injury.
Plummer D et al. Ann Emerg Med. 1992
28 had ED echo c/w 21 without ED echo
Survival: 100% in echo, 57.1% in nonecho
Time to Dx: 15 min echo, 42 min nonecho

77. Penetrating Cardiac Injury
The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study.
Rozycki GS: J Trauma. 1999
Pericardial scans performed in 261 patients
Sensitivity 100%, specificity 96.9%
PPV: 81% NPV:100%
Time interval BUS to OR: /- 5.9 min

78. Penetrating Cardiac Trauma
Emergency Department Echocardiography Improves Outcome in Penetrating Cardiac Injury
Plummer D, et al. Ann Emerg Med 21: , 1992.
“Since the introduction of immediate ED two-dimensional echocardiography, the time to diagnosis of penetrating cardiac injury has decreased and both the survival rate and neurologic outcome of survivors has improved.”

79. Stab wound to the chest
SAEM Pericardial effusion

80. Penetrating Cardiac Trauma
Echocardiographic signs of rising intrapericardial pressure
Collapse of RV free walls
Dilated IVC and hepatic veins
Goal: Early detection of pericardial effusion
Develops suddenly or discretely
May exist before clinical signs develop
Salvage rates better if detected before hypotension develops

81. Technical Problems Subcutaneous air Pneumopericardium
Mechanical ventilation
Scanning limited by:
Pain/tenderness
Spinal immobilization
Ongoing procedures

82. Technical Problems Narrow intercostal spaces Obesity Muscular chest
COPD
Calcified rib cartilages
Abdominal distention

83. Sonographic Pitfalls Pericardial versus pleural fluid Pericardial clot
Pericardial fat

84. Pericardial or Pleural Fluid
Left parasternal long axis:
Pericardial fluid does not extend posterior to descending aorta or left atrium
Subcostal:
No pleural reflection between liver and R sided chambers
A pleural effusion will not extend between to RV free wall and the liver

85. Pleural and Pericardial fluid
Pleural perica

86. Pleural effusion

87. Blunt Cardiac Trauma Cardiac contusion Cardiac rupture
Valvular disruption
Aortic disruption/dissection

88. Blunt Cardiac Trauma Pericardial effusion
Assess for wall motion abnormality
RV dyskinesis (takes the first hit)
Assess thoracic aorta:
Hematoma
Intimal flap
Abnormal contour
Valvular dysfunction or septal rupture

89. Cardiac Contusion Akinetic anterior RV wall Small pericardial effusion
Diminished ejection fraction

90. RV Contusion

91. Blunt Cardiac Trauma Assess thoracic aorta
Hematoma
Intimal flap
Abnormal contour
Requires TEE and expertise!
Valvular dysfunction or septal rupture
Requires expertise beyond our scope

92. Summary Bedside ECHO can help assess:
Overall cardiac wall motion
Identify clinically significant pericardial effusions
Useful in the assessment of the patient with:
Unexplained hypotension
Dyspnea
Thoracic trauma