Anthony J. Weekes MD, RDMS
Sarah A. Stahmer MD
For the SAEM US Interest Group

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

Secondary Indications
 Acute Cardiac Ischemia
 Pericardiocentesis
 External pacer capture
 Transvenous pacer placement

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

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

Main cardiac views



Parasternal
Subcostal
Apical

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

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\

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

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

Subcostal View

Subcostal View

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

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

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

Parasternal Long Axis

Parasternal Long Axis View

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

Parasternal Short Axis View

Parasternal Short Axis

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

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

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

Apical 4 chamber view

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

Apical 2 chamber view

Good look at inferior and anterior walls

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

Abnormal findings
Pericardial Effusion

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 nonproductive 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

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

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

Pericardial Fluid: Subcostal

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

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

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

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

Ventricular collapse in diastole

Tamponade

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

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

Cardiogenic shock

Dilated left ventricle

Hypocontractile walls

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

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

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

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

R sided leads

Non Traumatic
Resuscitation

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

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

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

ECHO in PEA

False positive cardiac motion
– Transthoracic pacemaker
– Positive pressure ventilation

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

Ineffective cardiac contractions

Optimizing Performance
 Assessing capture by transthoracic pacemaker
 Pericardiocentesis
 Transvenous pacemaker placement

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

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

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

Increase HR with PM “on”

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

Asystole w/ Transthoracic PM

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

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

Large pericardial effusion

Technique

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

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

Penetrating Chest Trauma

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

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

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: 12.1 +/- 5.9 min

Penetrating Cardiac Trauma
Emergency Department Echocardiography
Improves Outcome in Penetrating Cardiac
Injury
Plummer D, et al. Ann Emerg Med 21:709-712, 1992.
“Since the introduction of immediate ED twodimensional echocardiography, the time to diagnosis of penetrating cardiac injury has decreased and both the survival rate and neurologic outcome of survivors has improved.”

Stab wound to the chest

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

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

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

Sonographic Pitfalls
 Pericardial versus pleural fluid
 Pericardial clot
 Pericardial fat

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

Pleural and Pericardial fluid

Pleural effusion

Blunt Cardiac Trauma
 Cardiac contusion
 Cardiac rupture
 Valvular disruption
 Aortic disruption/dissection

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

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

RV Contusion

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

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