POCKET vs. FoCUS vs. FULL Echo
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1 3rd International Congress on Cardiovascular Imaging in Clinical Practice Athens 2018 POCKET vs. FoCUS vs. FULL Echo in Emergency CV Care Aleksandar N. Nešković Clinical Hospital Center Zemun Belgrade University School of Medicine
2 Ultrasound Imaging of the Heart Comprehensive (standard) echocardiography Emergency echo Goal-oriented echo FoCUS Limited echocardiography Type & Content of exam Hand-held US exam
3 Chest pain, Successful CPR in ambulance, Shock
4 ED Shock after CPR
5 ED Shock after CPR
6 ED Shock after CPR Referred for emergent surgery!
7 Is it really important how we name this examination and/or which imaging device is used, if it may save a life?
8 Why it may be important how we name this examination and/or which imaging device is used, in order to save a life?
9 POCKET vs. FoCUS vs. FULL echo in Emergency CV Care 1. Perspective and goals 2. Terminology 3. Arguments and philosophy 4. Reaching competence 5. Take Home Message
10 POCKET vs. FoCUS vs. FULL echo in Emergency CV Care 1. Perspective and goals 2. Terminology 3. Arguments and philosophy 4. Reaching competence 5. Take Home Message
11 Cardiac/Cardiac-Like Emergencies in ED Causes / Presentations ACS Acute Aortic Syndrome Acute Pulmonary Embolism ADHF Pneumothorax Acute pericarditis Tamponade Acute valve regurgitations Prosthetic valve dysfunction Chest pain Dyspnea Shock New murmur Chest trauma Cardiac arrest/cpr
12 Cardiac Emergencies Examination (diagnostic work-up) Accurate information Decision making Treatment
13 Ideally Experienced practitioner (always) Fully trained both in echo and acute/intensive cardiovascular care Fully equipped echo system
14 Reality Fully trained practitioners NOT avaliable everywhere It is impossible (and NOT necessary) to be always comprehensive Variety of US machines in use What really matters is: INFORMATION! Team work is crucial
15 POCKET vs. FoCUS vs. FULL echo in Emergency CV Care 1. Perspective and goals 2. Terminology 3. Arguments and philosophy 4. Reaching competence 5. Take Home Message
16 The use of Handheld Ultrasound Devices (HUD): a position statement of the European Association of Cardiovascular Imaging (2018 update)
17 Examination of the Heart by Ultrasound in Cardiovascular Emergencies Terminology Emergency echocardiography Goal-oriented (targeted) echocardiography FoCUS EAE Emerg Echo Recommendations, EHJ-CI 2013 EACVI Viewpoint on FoCUS, EHJ-CI 2014 EACVI FoCUS Cor Curr & Cor Syll, EHJ-CI 2018
18 FoCUS Emerg Echo Point-of-care Standardized, but restricted scanning protocol Operator responsible for decision making/th Training in FoCUS (not necessarily in ECHO!) Often HUD Comprehensive, standard echo FULL study of heart morphology and function Independent operator Full training in ECHO Fully equipped ECHO machines EACVI Viewpoint on FoCUS, EHJ-CI 2014
19 FoCUS 5 standard views 1 PLAX PSAX SIVC 3 3 S4CH 2 A4CH
20 E/B Targets of FoCUS Global LV systolic function and size Global RV systolic function and size Pericardial effusion Intravascular volume assessment Scenarios o Shock o Cardiac arrest o Chest pain o Chest/Cardiac trauma o Respiratory compromise Conditions o LV/RV ischem dysfunc o Cardiomyopathies o Myocarditis o Tamponade o Pulmonary embolism o Hypovolemia
21 1 st Point The SCOPE of the FoCUS is NOT to completely evaluate cardiac morphology and function. BUT to rapidly detect LIMITED number of critical cardiac conditions, requiring urgent medical attention. EACVI Viewpoint on FoCUS, EHJ-CI 2014
22 2 nd Point Both cardiologists & non-cardiologists can perform either ECHO or FoCUS o Clinical circumstances o Equipment o Expertise/Competence Crucial difference: the amount of information EACVI Viewpoint on FoCUS, EHJ-CI 2014
23 FoCUS Goal-Oriented Echo Targeted examination To solve specific, often critical and/or complex clinical dillemmas Fully trained echocardiographer! EACVI FoCUS Cor Curr & Cor Syll, EHJ-CI 2018
24 HUD: result of advanced technology
25 Currently available US machines according to their size and function Terminology Hand held ultrasound devices (HUD) Hand held imaging devices (HID) Pocket size imaging devices (PSID) Pocket size ultrasound devices (PSUD) Hand held echo devices (HED) Pocket size echo devices (PSED) HED/PSED HID/PSID HUD/PSUD Sicari R et al, EJE 2011
26 Currently available US machines according to their size and function Terminology Hand held ultrasound devices (HUD) Hand held imaging devices (HID) Pocket size imaging devices (PSID) Pocket size ultrasound devices (PSUD) Hand held echo devices (HED) Pocket size echo devices (PSED) HED/PSED HID/PSID HUD/PSUD HUD Hand held ultrasound device Sicari R et al, EJE 2011
27 HUD: Technical Limitations 2D + Color Doppler only NO spectral Doppler NO M-mode NO ECG NO other techniques (strain. 3D) Limited quantification: linear measurements only
28 3 rd Point HUD can be used for FoCUS/POCUS examinations! HUD cannot perform comprehensive/full emergency echocardiography due to technical limitations EACVI Viewpoint on FoCUS, EHJ-CI 2014
29 Why it may be important how we name the examination and/or which imaging device is used, in order to save a life?
30 Why Terminology is Important? To understand and respect differences To maintain the quality of information obtained by both FULL Echo and FoCUS, using various US devices To define specific education & training for all
31 POCKET vs. FoCUS vs. FULL echo in Emergency CV Care 1. Perspective and goals 2. Terminology 3. Arguments and philosophy 4. Reaching competence 5. Take Home Message
32 Cardiac Emergencies Examination (diagnostic work-up) Accurate information Decision making Treatment
33 Cardiac Emergencies FoCUS Focus Cardiac Ultrasound Echocardiography after FoCUS, whenever it is insufficient
34
35 Emergency Echo: the EACVI Recommendations EHJCI 2013
36
37
38 M. Gandhi Truth is one, paths are many
39 FoCUS with HUD in ICU; shock 7:34:01 7:34:18
40 FoCUS with HUD in ICU; shock 7:35:58 7:34:01 7:35:58 < 2 min!
41 In this situation, who needs TAPSE RV, LV, LA, LP.measurements RVOT flow acceleration time LV inflow profile Color Doppler M-mode DTI Strain
42 TEE MSCT
43 M. Gandhi O. Wild Truth is one, paths are many The pure and simple truth is rarely pure and never simple
44 Male, 46 yrs Severe dyspnea, tachypnea (7 days) No chest pain Op Colon Cancer 1 year ago TA 110/70 mmhg D-dimer 18,000 (230) CRP 160 (4) Le 14,500
45 ECG in the ER S1 Q3 T3 RV strain
46 FoCUS
47 Full ECHO
48 Full ECHO TR jet
49 Full ECHO Pulmonary artery flow profile
50 Acute pulmonary embolism?
51 Lung US Left Right
52 MSCT Pulmoangiography This is NOT a pulmonary embolism!
53 Back to Basics Acute Respiratory Distress Syndrome
54 FoCUS + ECHO + LUS Acute Cor Pulmonale in 25-50% of ARDS Vieillard-Baron A, et al Chest Vieillard-Baron A, et al. Crit Care Med. 2001
55 Neskovic AN, et al Emergency Echo: the EACVI Recommendations EHJCI 2013
56 Acute PE Right Heart Dilation in the ED Acute PE COPD ARDS RV infarct ARVC
57 M. Gandhi O. Wild US examination of the heart in emergency cardiac care! Truth is one, paths are many The pure and simple truth is rarely pure and never simple
58 POCKET vs. FoCUS vs. FULL echo in Emergency CV Care 1. Perspective and goals 2. Terminology 3. Arguments and philosophy 4. Reaching competence 5. Take Home Message
59 FoCUS-related Risks 1. Failure to detect important abnormalities 2. Misintepretation of limited data set or complex cases
60 Chest pain, w/o WMA, Tn negative Fellow FoCUS, Emergency Room
61 Chest pain, w/o WMA, Tn negative Expert Next morning, FULL echo
62 FoCUS, Fellow Expert, Full echo Supervision & Quality Control
63 Severe Dyspnea, Fever FoCUS, HUD
64 Severe Dyspnea, Fever Full Echo Descending thoracic aortic aneurysm Left atrial obliteration lung congestion (?) A mass attached to the aortic valve
65 FoCUS/HUD vs. FULL Echo Tip: Daylight (ICU, CCU, ED ) Increase GAIN!
66 Education & Training Emergency Echocardiography
67
68 To act as an Independent Operator in Emergency Echocardiography: Requirements for Training & Expertise Competence at least the same as for elective cases For Non-cardiologists - the same level of expertise as for cardiologists The EACVI Recommendations, EHJ-CI 2013
69 Independent operator Expert operator The EACVI Recommendations, EHJ-CI 2013
70 Education & Training FoCUS Focus Cardiac Ultrasound
71 In collaboration with: ACCA, EACTA, ESA, WINFOCUS EHJ-CI 2018
72 Aim To provide key principles and unifying framework for teaching and training of FoCUS that should result in competence in FoCUS for various medical professionals dealing with diagnostics and treatment of CV emergencies EACVI FoCUS Core Curriculum & Syllabus, EHJ-CI 2018 (in press)
73 EACVI FoCUS Core Curriculum & Syllabus Components of Training FoCUS technique Basic Lung US ACLS Compliance 1
74 Education & Training HUD Hand-held Ultrasound Devices The use of Handheld Ultrasound Devices (HUD): a position statement of the European Association of Cardiovascular Imaging (2018 update)
75 2011 Info for pts: NOT a substitute for FULL echocardiography Reported always as part of physical examination
76 2018 The use of Handheld Ultrasound Devices (HUD): a position statement of the European Association of Cardiovascular Imaging (2018 update) Work in progress, almost completed Cardim (document chair), Dalen, Delgado, Donal, Edvardsen, Galderisi, Ionescu, Neskovic, Popescu, Price, Sicari, Stefanidis, Voigt, Zamorano
77 Education, Training & Competence in HUD Competence in Imaging Acquisition & Interpretation + Specific Education & Training in HUD EACVI requirements for training and competence in Echocardiography or FoCUS + Basic Training & Certification + Practical training on HUD
78 EACVI Handheld Ultrasound Devices on-line Teaching Course Included in the ESC electronic Learning platform (ESCeL) Available to all EACVI members since December
79 POCKET vs. FoCUS vs. FULL echo in Emergency CV Care 1. Perspective and goals 2. Terminology 3. Arguments and philosophy 4. Reaching competence 5. Take Home Message
80 Neskovic AN, et al. Emergency Echo: the EACVI Recommendations EHJCI 2013
81 Emergency Echocardiograhy Service To improve institutional logistics 24-hour availability of doctor with independent operator level of competence in emerg echo Efficient consultative or on-call service for special echo techniques Team work Continuous supervision and quality control Emergency Echo: the EACVI Recommendations. EHJCI 2013
82 Team Work ED physician doing FoCUS (HUD) 1 ICU/CCU doctor ECHO expert Interventional cardiologist Patient should be referred for comprehensive ECHO whenever FoCUS findings are insufficient for the immediate patient management!
83 For critically ill patients, it is NOT important whether the life-saving information is acquired by non-cardiologist performing FoCUS, or by the expert cardiologist performing echocardiography. When such information is available, it has to be used. However, for the benefit of the patients, the involved medical professionals should have the necessary knowledge to understand the obtained information entirely, and to use it correctly, thoughtfully and with care. 2 EACVI Viewpoint on FoCUS, EHJ-CI 2014
84
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