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

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 murmurs Clear Lungs 80 y/o male Soft, non-tender Syncope at home Pulses weak No pulsatile Mass Emesis x 3 in ambulance Looks sick. No Edema No pain. 1

3/22/2016 Distal IVC Aorta Transvers e Learning Objectives Apical Long Axis • Understand cardiac anatomy • Understand image acquisition • Recognize common findings and pitfalls • Understand basic clinical applications • Recognize a few advanced applications 2

3/22/2016 Information Provided Outline By Bedside Ultrasound • Information Gained and its Applications The Basics: • Cardiac Anatomy & Image Acquisition • Pericardial Effusion • The Basics: Effusions, Function, IVC • Cardiac Function • Advanced: • Central Venous Pressure Tamponade, RV Strain, Aortic Root Dilation Applications Outline Central Venous Central Venous Pericardial Cardiac • Information Gained and its Applications Pressure Effusion Effusion Function • Cardiac Anatomy & Image Acquisition • Trauma • Dyspnea • The Basics: Effusions, Function, IVC • Cardiac Arrest • Sepsis • Advanced: • Hypotension • Fluid Resuscitation Tamponade, RV Strain, Aortic Root Dilation • Chest Pain • Diuresis 3

3/22/2016 Echocardiogram Bedside Echo: Anatomy Sonographic Planes Windows + Windows • 3 Windows = Views • Parasternal • Apical • Subxiphoid Bedside Echo: 4 Echocardiogram Cardiac Planes Views • Parasternal • 3 Primary Planes Long Axis • Parasternal • Long Axis Short Axis • Apical • Short Axis 4 • Four Chamber Chamber • Subxiphoid 4 Chamber 4

3/22/2016 Echocardiogram Image Acquisition & • Small footprint AnatomyWindow Probe Selection Differences • Low frequency COPD, Barrel Chest, Cardiomegaly, Tall and Thin Large Abdomen Echocardiogram Echocardiogram Anatomy AnatomyWindows and Axis Differences Axes • Windows & axes vary • First: Find your Window • THEN: Adjust the Axis Vertical Axis Horizontal Axis 5

3/22/2016 Parasternal Long Axis Controversy: View Probe Orientation (The only one that differs) General Radiology/EM Cardiology • Scan from pts • Scan from pts RIGHT LEFT • Indicator • Indicator Screen Screen LEFT RIGHT Moore, C. Current issues with emergency cardiac ultrasound probe and image conventions. Acad Emerg Med 2008; 15: 278-284 Parasternal Long Axis What setting does my View machine use? Probe Indicator Toward right shoulder • Choose cardiac probe and preset • Look for the indicator • Can L/R invert • Can save default 6

3/22/2016 Long Axis Plane Cardiac Planes Long Axis RV RV Short Axis Ao Ao LV LV LA LA DTA DTA Parasternal Long Axis Parasternal Long Axis View View RV RV • Tips: LV LV RV RV • Stay close to sternum • End-expiratory hold LV LV Ao • Difficult in COPD Mitral Valve Leaflets DTA 7

3/22/2016 Parasternal Short Axis Short Axis Plane Indicator 90º CCW from Long Axis Chest Wall RV RV LV LV Back Parasternal Short Axis View View Tips: • Try to maintain circular LV • End-expiratory hold • View varies depending on level of heart 8

3/22/2016 Apical 4 Chamber Apical 4 Chamber View View Indicator similar to Short Axis, Perpendicular plane Plane is 90º from Short Axis, Window is at the PMI 4 Chamber Plane 4 Chamber Plane Apical Window RV RV RA RA LV LV LA LA 9

3/22/2016 Apical 4 Chamber Apical 4 Chamber View View • Tips: RV RV LV LV • Left lateral decubitus RA RA • End-expiratory hold LA LA • Under the breast fold • Aim sound waves toward right scapula Subxiphoid 4 Chamber Subxiphoid 4 Chamber View View Liver LA LV RA RV RV RA LV LA 10

3/22/2016 Subxiphoid 4 Chamber Subxiphoid 4 Chamber View View Liver RV RA LV LV LA LA • Tips: • Firm pressure • Inspiratory hold • Bowel Gas? Try right of midline IVC IVC Indicator toward chin Aim towards thoracic spine 11

3/22/2016 IVC IVC Image the IVC entering Right Atrium RA IVC IVC IVC & CVP Goals • Assess for IVC fullness • Assess % collapse with spontaneous inspiration • Just inferior to hepatic vein junction 12

3/22/2016 Pitfalls: IVC vs Aorta Transverse View • Empties into heart ● Flows deep to heart • Flows through liver ● Flows deep to Spine liver IVC Aorta • Undulating Pulsation ● Bounding Pulsation IVC IVC • Avoiding Pitfalls: • Do NOT scan from the far lateral torso • (IVC collapses Ant-Post, not laterally) X • Will appear dilated with minimal variation 13

3/22/2016 IVC IVC • Tips: • Maintain axis along upper IVC • May need to scan through right anterior ribs • Differentiate IVC vs Aorta Scanning Flow Outline • Parasternal Long • Information Gained and its Applications • Parasternal • Cardiac Anatomy & Image Acquisition Short • The Basics: Effusions, Function, IVC • Apical 4 • Advanced: • SubXiphoid Tamponade, RV Strain, Aortic Root • IVC Dilation 14

3/22/2016 Basics: Pericardial Effusions Pericardial Effusions Parasternal Long Axis • Anechoic signal (Black) • Between myocardium and pericardium • Generally dependent • Except in trauma or post-op, clinically significant effusions are circumferential Pericardial Effusions Pericardial Effusions Subxiphoid 4 Chamber False Positives • Epicardial fat pad • Left pleural effusion • Ascites 15

3/22/2016 False Positive: Fat Pericardial Effusions Pad False Positive: Fat Pad • Echogenic • Moves with myocardium • Not displaced by heart motion • Usually not dependent False Positive: Fat False Positive: L Pleural False Positive: L Pleural Pad Effusion Effusion Pericardium DTA 16

3/22/2016 False Positive: L Pleural False Positive: L Pleural Pericardial Effusions Effusion Effusion False Positive: L Pleural Effusion Pericardial 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 False Positive: False Positive: L Pleural False Positive: L Pleural Effusion Effusion Ascites Use FAST LUQ view to confirm 17

3/22/2016 Pericardial Effusions Pericardial Effusions False Negative: Blood False Positive: Ascites Clot • Only seen in subxiphoid view • Clotting blood can appear from • Will often disappear with deep anechoic to hyperechoic, to mixed. • Look for your landmarks inspiration • Confirm ascites in abdominal views • 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 18

3/22/2016 Basics: E-Point Septal LV Function Separation (EPSS) • General estimate • Shortest distance • Dead to Hyperdynamic from anterior mitral • Parasternal long and short axes, look at valve leaflet to LV • Anterior mitral valve leaflet (EPSS) septum • Strong inverse (should come within 8mm of septal wall) correlation with • General contraction of LV 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. E-Point Septal LV Function Separation (EPSS) • PS long axis Image center of LV (No visible chordae) • M-mode through anterior mitral valve tip Septum • Measure minimum Mitral distance to LV STANDSTILL STANDSTILL Valve Septum • Normal < 8mm 19

3/22/2016 LV Function LV Function Agonal Agonal Severely Depressed Severely Depressed LV Function LV Function Moderately Depressed Moderately Depressed Moderately Depressed Moderately Depressed 20

3/22/2016 LV Function LV Function Hyperdynamic Hyperdynamic Normal Normal Outline IVC and CVP Inspiratory IVC Distension CVP • Information Gained and its Applications collapse • Cardiac Anatomy & Image Acquisition Small Complete <5cm H20 • The Basics: Effusions, Function, IVC Moderate to Full >50% 5-10 • Advanced: Moderate to Full <50% 10-15 Tamponade, RV Strain, Aortic Root Large (>2.5cm) Minimal 15-20cm H20 Dilation Large (>2.5cm) None >20cm H20 21

3/22/2016 IVC IVC 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 IVC IVC Full, with complete collapse Full, with partial collapse 22

3/22/2016 IVC IVC & CVP Fill the Tank: In hypotension, Give fluids until it collapses less than 50% • >50% Collapse = >50% Collapse = CVP < 8mmHg (10cmH20) ) Distended, with no variation IVC and CVP Outline M-Mode • Information Gained and its Applications • Cardiac Anatomy & Image Acquisition • M-Mode to • The Basics: Effusions, Function, IVC visualize and • Advanced: Quantify Tamponade, RV Strain, Aortic Root Collapse Dilation 23