Disclosures. Cardiac Ultrasound. Introductory Case. 80 y/o male Syncope at home Emesis x 3 in ambulance Looks sick. No pain.

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1 Disclosures Cardiac Ultrasound Justin A Davis, MD MPH RDMS Subchief for Emergency Ultrasound Kaiser Permanente East Bay Medical Center I have nothing to disclose. Introductory Case HR 118 BP 65/43 RR 27 O 2 99% Talking fine 80 y/o male Syncope at home Emesis x 3 in ambulance Looks sick. No pain. Clear Lungs Pulses weak No Edema No murmurs Soft, non-tender No pulsatile Mass 1

2 Distal Aorta Transvers e Apical Long Axis Learning Objectives Understand cardiac anatomy Understand image acquisition Recognize common findings and pitfalls Understand basic clinical applications Recognize a few advanced applications 2

3 Outline Information Gained and its Applications Cardiac Anatomy & Image Acquisition The Basics: Effusions, Function, Advanced: Tamponade, RV Strain, Aortic Root Dilation Information Provided By Bedside Ultrasound The Basics: Pericardial Effusion Cardiac Function Central Venous Pressure Pericardial Effusion Trauma Cardiac Arrest Hypotension Chest Pain Applications Cardiac Function Central Venous Pressure Dyspnea Sepsis Fluid Resuscitation Diuresis Outline Information Gained and its Applications Cardiac Anatomy & Image Acquisition The Basics: Effusions, Function, Advanced: Tamponade, RV Strain, Aortic Root Dilation 3

4 Echocardiogram Anatomy Windows + = Views Planes 3 Windows Parasternal Apical Bedside Echo: Sonographic Windows Subxiphoid Bedside Echo: Cardiac Planes 3 Primary Planes Long Axis Short Axis Four Chamber 4 Echocardiogram Views Parasternal Long Axis Parasternal Short Axis Apical 4 Chamber Subxiphoid 4 Chamber 4

5 Image Small footprint Acquisition & Probe Selection Echocardiogram AnatomyWindow Differences Low frequency COPD, Barrel Chest, Tall and Thin Cardiomegaly, Large Abdomen Echocardiogram Anatomy Axis Differences Echocardiogram AnatomyWindows and Axes Windows & axes vary Vertical Axis Horizontal Axis First: Find your Window THEN: Adjust the Axis 5

6 Controversy: Probe Orientation General Radiology/EM Cardiology Parasternal Long Axis View (The only one that differs) Scan from pts RIGHT Scan from pts LEFT Indicator Screen LEFT Indicator Screen RIGHT Moore, C. Current issues with emergency cardiac ultrasound probe and image conventions. Acad Emerg Med 2008; 15: What setting does my machine use? Choose cardiac probe and preset Look for the indicator Can L/R invert Can save default Parasternal Long Axis View Probe Indicator Toward right shoulder 6

7 Cardiac Planes Long Axis Plane Long Axis Short Axis Ao RV LV LA DTA Parasternal Long Axis View RV LV Ao RV LV Mitral Valve Leaflets Parasternal Long Axis View Tips: Stay close to sternum End-expiratory hold Difficult in COPD DTA 7

8 Parasternal Short Axis Indicator 90º CCW from Long Axis Short Axis Plane RV LV Chest Wall Back View Parasternal Short Axis View Tips: Try to maintain circular LV End-expiratory hold View varies depending on level of heart 8

9 Apical 4 Chamber View Apical 4 Chamber View Indicator similar to Short Axis, Perpendicular plane Plane is 90º from Short Axis, Window is at the PMI 4 Chamber Plane Apical Window 4 Chamber Plane RA LA RV LV 9

10 RV RA Apical 4 Chamber View LV LA Apical 4 Chamber View Tips: Left lateral decubitus End-expiratory hold Under the breast fold Aim sound waves toward right scapula Subxiphoid 4 Chamber View Subxiphoid 4 Chamber View LA RA LV RV Liver RV RA LV LA 10

11 Liver RV RA LA Subxiphoid 4 Chamber View LV Subxiphoid 4 Chamber View Tips: Firm pressure Inspiratory hold Bowel Gas? Try right of midline Indicator toward chin Aim towards thoracic spine 11

12 Image the entering Right Atrium RA Goals & CVP Assess for fullness Assess % collapse with spontaneous inspiration Just inferior to hepatic vein junction 12

13 Pitfalls: vs Aorta Transverse View Empties into heart heart Flows deep to Flows through liver liver Undulating Pulsation Pulsation Flows deep to Bounding Spine Aorta Avoiding Pitfalls: Do NOT scan from the far lateral torso ( collapses Ant-Post, not laterally) Will appear dilated with minimal variation X 13

14 Tips: Maintain axis along upper May need to scan through right anterior ribs Differentiate vs Aorta Scanning Flow Parasternal Long Parasternal Short Apical 4 SubXiphoid Outline Information Gained and its Applications Cardiac Anatomy & Image Acquisition The Basics: Effusions, Function, Advanced: Tamponade, RV Strain, Aortic Root Dilation 14

15 Basics: Pericardial Effusions Anechoic signal (Black) Between myocardium and pericardium Generally dependent Except in trauma or post-op, clinically significant effusions are circumferential Pericardial Effusions Parasternal Long Axis Pericardial Effusions Subxiphoid 4 Chamber Pericardial Effusions False Positives Epicardial fat pad Left pleural effusion Ascites 15

16 False Positive: Fat Pad Pericardial Effusions False Positive: Fat Pad Echogenic Moves with myocardium Not displaced by heart motion Usually not dependent False Positive: Fat Pad False Positive: L Pleural Effusion Pericardium DTA 16

17 Pericardial Effusions False Positive: L Pleural Effusion Only seen posterior/lateral views In parasternal long axis, extends deep to the descending thoracic aorta (not between DTA and heart) Use FAST splenorenal view to confirm False Positive: L Pleural Pericardial Effusion Effusion DTA Pleural Effusion False Positive: L Pleural Use FAST LUQ view to confirm Effusion False Positive: Ascites 17

18 Pericardial Effusions False Positive: Ascites Only seen in subxiphoid view Will often disappear with deep inspiration Confirm ascites in abdominal views Pericardial Effusions False Negative: Blood Clot Clotting blood can appear from anechoic to hyperechoic, to mixed. Look for your landmarks Check multiple views False Negative: Clot Outline Information Gained and its Applications Cardiac Anatomy & Image Acquisition The Basics: Effusions, Function, Advanced: Tamponade, RV Strain, Aortic Root Dilation 18

19 Basics: LV Function General estimate Dead to Hyperdynamic Parasternal long and short axes, look at Anterior mitral valve leaflet (EPSS) (should come within 8mm of septal wall) General contraction of LV E-Point Septal Separation (EPSS) Shortest distance from anterior mitral valve leaflet to LV septum Strong inverse correlation with LVEF Elagha, Abdalla, and Anthon Fuisz. Mitral Valve E-Point to Septal Separation (EPSS) Measurement by Cardiac Magnetic Resonance Imaging as a Quantitative Surrogate of Left Ventricular Ejection Fraction (LVEF). Journal of Cardiovascular Magnetic Resonance 14.Suppl 1 (2012): P154. PMC. Web. 20 Mar E-Point Septal Separation (EPSS) PS long axis Image center of LV (No visible chordae) M-mode through anterior mitral valve tip Measure minimum distance to LV Septum Normal < 8mm Septum Mitral Valve LV Function STANDSTILL 19

20 LV Function LV Function Agonal Severely Depressed LV Function LV Function Moderately Depressed Moderately Depressed 20

21 LV Function LV Function Normal Hyperdynamic Outline Information Gained and its Applications Cardiac Anatomy & Image Acquisition The Basics: Effusions, Function, Advanced: Tamponade, RV Strain, Aortic Root Dilation and CVP Distension Inspiratory collapse CVP Small Complete <5cm H20 Moderate to Full >50% 5-10 Moderate to Full <50% Large (>2.5cm) Minimal 15-20cm H20 Large (>2.5cm) None >20cm H20 21

22 and CVP However, don t have to use numbers Give a general estimate, trend is more important than single measurement Is the CVP... low, moderate, high, or extremely high? Nearly empty, with complete collapse Full, with complete collapse Full, with partial collapse 22

23 Fill the Tank: In hypotension, Give fluids until it collapses less than 50% & CVP Distended, with no variation >50% Collapse = CVP < 8mmHg (10cmH20) M-Mode to visualize and Quantify Collapse and CVP M-Mode Outline Information Gained and its Applications Cardiac Anatomy & Image Acquisition The Basics: Effusions, Function, Advanced: Tamponade, RV Strain, Aortic Root Dilation 23

24 Advanced Finding: Impending Tamponade (Clinical Diagnosis) What does RA or RV collapse look like? 1) distention w/o resp. variation (ALMOST ALWAYS) 2) Diastolic RA or RV Collapse RA Diastolic Collapse Seen in 75% RV Diastolic Collapse Seen in 25% 24

25 RV Collapse? Tamponade M-Mode Is it collapsing in Diastole? In Diastole the Mitral Valve is open M-Mode Parasternal long, short, or subxiphoid M - Mode RV Collapse RV Free Wall Ant. Mitral Valve RV wall moving inward while mitral valve is open Pulsus Paradoxus Pulsed Wave Doppler In tamponade, exaggerated drop in stroke volume and BP with inspiration Apical 4 or 5 chamber view Mitral valve inflow, LV outflow, Tricuspid inflow Doppler gate distal distal to valve tips Look for drop >25% with inspiration 25

26 Pulsus Paradoxus Outline > 25% drop Information Gained and its Applications Cardiac Anatomy & Image Acquisition The Basics: Effusions, Function, Advanced: Tamponade, RV Strain, Aortic Root Dilation Advanced Finding: RV Strain When RV is pushing against high pressure (eg. massive PE) RV distended and hardly squeezing Sometimes LV is compressed/empty is plethoric (full) Normal RV - Large & Hypokinetic Parasternal Long Axis LV - Small & Hyperkinetic 26

27 Normal Parasternal Short Axis RV - Large & Hypokinetic Normal Apical 4 Chamber RV - Large & Hypokinetic D -Shaped D Left Ventricle (Septal Wall Flattening) LV - Small & Hyperkinetic LV - Small & Hyperkinetic RV:LV >1 (normal<1) Need to image both tricuspid and mitral valves well to comment on RV:LV ratio = Plethoric (Full, Stiff) RV Dysfunction: TAPSE Tricuspid Annular Plane Systolic Excursion Apical 4 Chamber M-mode Tricuspid Annulus at RV free wall Normal excursion > 16mm 27

28 RV Dysfunction: TAPSE RV Dysfunction: TAPSE M-Mode RV Dysfunction: Tissue Doppler Select TDI mode on your Doppler Focuses on tissue velocity, not fluid velocity Upward systolic motion is S 1 wave Normal S 1 > 10 cm/s S E A Outline Information Gained and its Applications Cardiac Anatomy & Image Acquisition The Basics: Effusions, Function, Advanced: Tamponade, RV Strain, Aortic Root Dilation 28

29 Advanced Finding Dilated Aortic Root 90% of Ascending aortic dissection have dilated ascending aorta (>4cm) Parasternal long axis and 1-2 rib spaces superior Image 3-5 cm length of ascending Ao Neither sensitive nor specific, but may push you along towards the diagnosis Aortic Root Dilation Aortic Root Dilation Aortic Root Dilation 5.4cm Parasternal Long Axis Aortic Valve Annulus is at end of septum, Anything in aorta distal to that is a dissection flap, not a leaflet 29

30 Outline Information Gained and its Applications Cardiac Anatomy & Image Acquisition The Basics: Effusions, Function, Advanced: Tamponade, RV Strain, Aortic Root Dilation Bedside Echo Summary The Basics: Significant Pericardial Effusion: Yes/No Circumferential hypoechoic fluid displaced by heart motion LV Function: Gestalt estimate Note LV contraction and Anterior Mitral Valve leaflet approaching the septum : Gestalt CVP estimation Note size and collapse with respiration Bedside Echo Summary Advanced Findings: Impending Tamponade: Large effusion, plethoric, +/- RA/RV collapse RV Strain: RV appears enlarged and poorly contracting LV is D-shaped on short axis Aortic Root Dilation: High parasternal long axis, normal <4cm 30