Disclosures Cardiac Ultrasound I have nothing to disclose. Justin - - PDF document

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Disclosures Cardiac Ultrasound I have nothing to disclose. Justin - - PDF document

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3/22/2016 Disclosures Cardiac Ultrasound I have nothing to disclose. Justin A Davis, MD MPH RDMS Subchief for Emergency Ultrasound Kaiser Permanente East Bay Medical Center BP 65/43 RR 27 O 2 99% HR 118 Introductory Case Talking fine No

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Cardiac Ultrasound

Justin A Davis, MD MPH RDMS Subchief for Emergency Ultrasound Kaiser Permanente East Bay Medical Center

Disclosures

  • I have nothing to disclose.

Introductory Case

80 y/o male Syncope at home Emesis x 3 in ambulance Looks sick. No pain.

Talking fine Clear Lungs No murmurs Pulses weak No Edema

HR 118 BP 65/43 RR 27 O2 99%

Soft, non-tender No pulsatile Mass

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3/22/2016 2

Distal Aorta Transvers e IVC 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
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Outline

  • Information Gained and its Applications
  • Cardiac Anatomy & Image Acquisition
  • The Basics: Effusions, Function, IVC
  • Advanced:

Tamponade, RV Strain, Aortic Root Dilation

Information Provided By Bedside Ultrasound

  • Pericardial Effusion
  • Cardiac Function
  • Central Venous Pressure

The Basics:

Applications

  • Trauma
  • Cardiac Arrest
  • Hypotension
  • Chest Pain

Cardiac Function Effusion Pericardial Effusion Central Venous Central Venous Pressure

  • Dyspnea
  • Sepsis
  • Fluid Resuscitation
  • Diuresis

Outline

  • Information Gained and its Applications
  • Cardiac Anatomy & Image Acquisition
  • The Basics: Effusions, Function, IVC
  • Advanced:

Tamponade, RV Strain, Aortic Root Dilation

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= Views

Echocardiogram Anatomy

Windows Planes +

  • 3 Windows
  • Parasternal
  • Apical
  • Subxiphoid

Bedside Echo: Sonographic Windows 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

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Image Acquisition & Probe Selection

  • Small footprint
  • Low frequency

Echocardiogram AnatomyWindow Differences

COPD, Barrel Chest, Tall and Thin Cardiomegaly, Large Abdomen

Echocardiogram Anatomy Axis Differences

Vertical Axis Horizontal Axis

  • Windows & axes vary
  • First:

Find your Window

  • THEN: Adjust the Axis

Echocardiogram AnatomyWindows and Axes

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Probe Orientation

  • Scan from pts

RIGHT

  • Indicator

Screen LEFT

General Radiology/EM Cardiology

Controversy:

  • Scan from pts

LEFT

  • Indicator

Screen RIGHT

Moore, C. Current issues with emergency cardiac ultrasound probe and image conventions. Acad Emerg Med 2008; 15: 278-284

Parasternal Long Axis View

(The only one that differs)

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

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Long Axis Short Axis Cardiac Planes LV LV

RV RV Ao Ao

DTA DTA

LA LA

Long Axis Plane LV LV

RV RV

Parasternal Long Axis View

LV LV

RV RV Ao

DTA

Mitral Valve Leaflets

  • Tips:
  • Stay close to sternum
  • End-expiratory hold
  • Difficult in COPD

Parasternal Long Axis View

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Parasternal Short Axis

Indicator 90º CCW from Long Axis

Short Axis Plane LV LV

RV RV Chest Wall Back

View Parasternal Short Axis View

Tips:

  • Try to maintain circular LV
  • End-expiratory hold
  • View varies depending on level of heart
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Apical 4 Chamber View

Plane is 90º from Short Axis, Window is at the PMI

Apical 4 Chamber View

Indicator similar to Short Axis, Perpendicular plane

4 Chamber Plane LV LV

RV RV LA LA RA RA

Apical Window 4 Chamber Plane

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LV LV

RV RV LA LA RA RA

Apical 4 Chamber View 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

LV

LA

RV

RA

Subxiphoid 4 Chamber View

Liver

LV

LA

RV

RA

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Liver

RA RV LA LA

LV LV

Subxiphoid 4 Chamber View

  • Tips:
  • Firm pressure
  • Inspiratory hold
  • Bowel Gas? Try right of midline

Subxiphoid 4 Chamber View IVC IVC

Indicator toward chin Aim towards thoracic spine

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IVC

RA IVC

IVC

Image the IVC entering Right Atrium

  • Assess for IVC fullness
  • Assess % collapse with spontaneous

inspiration

  • Just inferior to hepatic vein junction

IVC Goals IVC & CVP

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IVC vs Aorta

  • Empties into heart
  • Flows deep to

heart

  • Flows through liver
  • Flows deep to

liver

  • Undulating Pulsation
  • Bounding

Pulsation

Pitfalls:

Transverse View

Spine

Aorta IVC

IVC

  • Avoiding Pitfalls:
  • Do NOT scan from the far lateral torso
  • (IVC collapses Ant-Post, not laterally)
  • Will appear dilated with minimal variation

IVC

X

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IVC IVC

  • Tips:
  • Maintain axis along upper IVC
  • May need to scan through right anterior

ribs

  • Differentiate IVC vs Aorta

Scanning Flow

  • Parasternal Long
  • Parasternal

Short

  • Apical 4
  • SubXiphoid
  • IVC

Outline

  • Information Gained and its Applications
  • Cardiac Anatomy & Image Acquisition
  • The Basics: Effusions, Function, IVC
  • Advanced:

Tamponade, RV Strain, Aortic Root Dilation

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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
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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

DTA Pericardium

False Positive: L Pleural

Effusion

False Positive: L Pleural

Effusion

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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

DTA

Pleural Effusion Pericardial Effusion

False Positive: L Pleural

Effusion

False Positive: L Pleural

Effusion

False Positive: L Pleural

Effusion

False Positive: L Pleural

Effusion

Use FAST LUQ view to confirm

False Positive: Ascites

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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, IVC
  • Advanced:

Tamponade, RV Strain, Aortic Root Dilation

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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. 2016.

  • 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

E-Point Septal Separation (EPSS)

Septum Mitral Valve

LV Function

STANDSTILL STANDSTILL

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LV Function

Agonal Agonal

LV Function

Severely Depressed Severely Depressed

LV Function Moderately Depressed Moderately Depressed LV Function Moderately Depressed Moderately Depressed

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LV Function

Normal Normal

LV Function

Hyperdynamic Hyperdynamic

Outline

  • Information Gained and its Applications
  • Cardiac Anatomy & Image Acquisition
  • The Basics: Effusions, Function, IVC
  • Advanced:

Tamponade, RV Strain, Aortic Root Dilation

IVC and CVP

IVC Distension Inspiratory collapse CVP Small Complete <5cm H20 Moderate to Full >50% 5-10 Moderate to Full <50% 10-15 Large (>2.5cm) Minimal 15-20cm H20 Large (>2.5cm) None >20cm H20

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  • 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?

IVC and CVP IVC

Nearly empty, with complete collapse

IVC

Full, with complete collapse

IVC

Full, with partial collapse

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IVC

  • Distended, with no variation

IVC & CVP

>50% Collapse = ) >50% Collapse = CVP < 8mmHg (10cmH20) Fill the Tank: In hypotension, Give fluids until it collapses less than 50%

IVC and CVP M-Mode

  • M-Mode to

visualize and Quantify Collapse

Outline

  • Information Gained and its Applications
  • Cardiac Anatomy & Image Acquisition
  • The Basics: Effusions, Function, IVC
  • Advanced:

Tamponade, RV Strain, Aortic Root Dilation

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  • 1) IVC distention w/o resp. variation (ALMOST

ALWAYS)

  • 2) Diastolic RA or RV Collapse

Advanced Finding: Tamponade Impending

(Clinical Diagnosis)

What does RA or RV collapse look like? RA Diastolic Collapse

Seen in 75%

  • RV Diastolic Collapse

Seen in 25%

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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

  • pen

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
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Pulsus Paradoxus

> 25% drop

Outline

  • Information Gained and its Applications
  • Cardiac Anatomy & Image Acquisition
  • The Basics: Effusions, Function, IVC
  • 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
  • IVC is plethoric (full)

Parasternal Long Axis RV - Large & Hypokinetic LV - Small & Hyperkinetic Normal

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Parasternal Short Axis

“D”-Shaped Left Ventricle D

RV - Large & Hypokinetic LV - Small & Hyperkinetic (Septal Wall Flattening) Normal RV - Large & Hypokinetic LV - Small & Hyperkinetic RV:LV >1 (normal<1) Apical 4 Chamber Normal Need to image both tricuspid and mitral valves well to comment on RV:LV ratio Need to image both tricuspid and mitral valves well to comment on RV:LV ratio

  • IVC

IVC= Plethoric (Full, Stiff)

  • Tricuspid Annular Plane Systolic

Excursion

  • Apical 4 Chamber
  • M-mode Tricuspid Annulus at RV free wall
  • Normal excursion > 16mm

RV Dysfunction: TAPSE

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RV Dysfunction: TAPSE RV Dysfunction: TAPSE

M-Mode

RV Dysfunction: Tissue Doppler

S E A

  • Select “TDI” mode
  • n your Doppler
  • Focuses on tissue

velocity, not fluid velocity

  • Upward systolic

motion is “S1 wave”

  • Normal S1 > 10

cm/s

Outline

  • Information Gained and its Applications
  • Cardiac Anatomy & Image Acquisition
  • The Basics: Effusions, Function, IVC
  • Advanced:

Tamponade, RV Strain, Aortic Root Dilation

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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

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

Aortic Root Dilation

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Outline

  • Information Gained and its Applications
  • Cardiac Anatomy & Image Acquisition
  • The Basics: Effusions, Function, IVC
  • Advanced:

Tamponade, RV Strain, Aortic Root Dilation

  • 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

  • IVC: Gestalt CVP estimation

Note IVC size and collapse with respiration

Bedside Echo Summary

  • Advanced Findings:
  • Impending Tamponade:

Large effusion, plethoric IVC, +/- 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

Bedside Echo Summary