Emergency Cardiac Ultrasound:

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EmergencyCardiac UltrasoundQuestions

• Stephanie J. Doniger, MD FAAP

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Emergency Cardiac US

• Focused questions heart, pericardium
• Potentially life-threatening conditions
• Yes-No questions

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Questions

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

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Abnormal Cardiac US

• Cardiac arrest, asystole
• Pericardial Fluid
• Hemopericardium
• Cardiac Tamponade

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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 8610-615, 2001
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M-Mode
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Wall Motion

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

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Hypokinesia
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Pericardial Fluid

• Presence of anechoic fluid _at_ pericardial space
• Local systemic d/os, trauma, idiopathic
• Acute vs. chronic
• Echogenic/gray, swirling
• Pus, blood fibrin, malignant
• Up to 50 cc may be physiologic

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Pericardial Effusions
Small Moderate Large
Location Posterior Inferior to LV Extends to apex Circumscribes heart
Meas. _at_ Diastole lt10 mm 10-15 mm gt15 mm
maximal width of pericardial stripe
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Pericardial EffusionSubxiphoid
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Pericardial EffusionPSSA
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Pericardial EffusionPenetrating 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 10973-977, 2003
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Pericardial EffusionAtraumatic

• 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
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NOT Pericardial Effusions

• Pericardial fat pad
• Anterior
• Pleural effusions
• Intraabdominal fluid

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Tamponade

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

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Tamponade US

• Circumferential pericardial effusion
• Scalloping of RV
• Diastolic collapse of RV (or RA)
• Swinging heart
• CCW rotational movement
• Dilated IVC without inspiratory variation

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Tamponade
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Tamponade
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Do you have questions?