Emergency Cardiac Ultrasound: “Questions”

1. EmergencyCardiac Ultrasound:“Questions” • Stephanie J. Doniger, MD FAAP

2. Emergency Cardiac US • Focused questions: heart, pericardium • Potentially life-threatening conditions • Yes-No questions

3. Questions • Is cardiac activity present? • Global cardiac hyper/hypo -kinesis? • Is there a pericardial effusion? • Tamponade?

4. Abnormal Cardiac US • Cardiac arrest, asystole • Pericardial Fluid • Hemopericardium • Cardiac Tamponade

5. Cardiac Activity • Sonographic asystole • Absence of ventricular contraction, M-mode • PEA eval. • *32% w/cardiac contractions • No pts w/cardiac standstill had ROSC • 73% w/contractions had ROSC • Prognosis; stop resuscitative efforts? *Salen, et al. Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes? Acad Emerg Med 8:610-615, 2001

6. M-Mode

7. Wall Motion • LV dysfunction • Abnormal wall function • Abnormal ventric emptying/relaxation • Hypokinesia, akinesis, dyskinesia (paradoxic)

8. Hypokinesia

9. Pericardial Fluid • Presence of anechoic fluid @ pericardial space • Local & systemic d/o’s, trauma, idiopathic • Acute vs. chronic • Echogenic/gray, swirling • Pus, blood + fibrin, malignant • Up to 50 cc may be physiologic

10. Pericardial Effusions *maximal width of pericardial stripe

11. Pericardial EffusionSubxiphoid

12. Pericardial EffusionPSSA

13. Pericardial Effusion:Penetrating Trauma • 100% Sensitivity (Plummer, 1992) • Reduced time to Dx & Disposition • 42.4 min vs. 15.5 min • Improved survival • 57.1 % vs. 100% Randazzo MR et al. Accuracy of emergency physician assessment of LV ejection fraction and central venous pressure using echocardiography. Acad Emerg Med 10:973-977, 2003

14. Pericardial Effusion:Atraumatic • 103/515 high-risk criteria • Unexplained hypotension/dyspnea, CHF, cancer, uremia, lupus or pericarditis • 97.5% accuracy of bedside ECHO (EP) Madavia, et al. Bedside echocardiography by emergency physicians. Ann Emerg Med 38: 377-382, 2001

15. NOT Pericardial Effusions • Pericardial fat pad • Anterior • Pleural effusions • Intraabdominal fluid

16. Tamponade • Compression of the heart by blood/fluid btwn myocardium & pericardium • Rate of fluid accumulation > amt fluid • As little as 150 mL • Clinical diagnosis • Clinical picture; triad muffled heart tones, hypotension, JVD • Hemodynamics

17. Tamponade: US • Circumferential pericardial effusion • “Scalloping” of RV • Diastolic collapse of RV (or RA) • Swinging heart • CCW rotational movement • Dilated IVC without inspiratory variation

18. Tamponade

19. Tamponade

20. Do you have questions?