ECHOCARDIOGRAPHY What the intensivist should know OVERVIEW - - PowerPoint PPT Presentation

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ECHOCARDIOGRAPHY What the intensivist should know OVERVIEW - - PowerPoint PPT Presentation

Dec 25, 2022 689 likes •2.07k views

ECHOCARDIOGRAPHY What the intensivist should know OVERVIEW Background Why ECHO? Limitations How to learn ECHO What you need to know Where we are heading BACKGROUND BACKGROUND COLLEGE AKNOWLEDGEMENT WHY DO WE NEED TO

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What the intensivist should know…

ECHOCARDIOGRAPHY

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OVERVIEW

  • Background
  • Why ECHO?
  • Limitations
  • How to learn ECHO
  • What you need to know
  • Where we are heading
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BACKGROUND

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BACKGROUND

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COLLEGE AKNOWLEDGEMENT

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WHY DO WE NEED TO LEARN ECHO?

  • Filling the void
  • Differentiating shock
  • Tamponade post cardiac surgery
  • Management of cardiovascular supports
  • ECHO in cardiac arrest
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LIMITATIONS

  • Scope of practice
  • Impact of
  • False positives
  • False negatives
  • Formal studies
  • Advanced studies
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HOW TO LEARN ECHO

  • BOOKS
  • COURSES
  • WEBSITES
  • HANDS ON SACNNING
  • SUPERVISION
  • POST GRAD CERT/DIPLOMA
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WEBSITES

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CICM GUIDELINE

  • Attend an approved ECHO course
  • Find a supervisor
  • Perform 35 focussed cardiac ultrasound cases
  • Record images/ Write in notes
  • Complete and pass an online MCQ exam @CICM
  • In the furture- there may be a ‘live’ exam
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CICM GUIDELINE

  • Basic physics
  • Machine setup
  • Patient details
  • Image optimization
  • Basic views (PLA/ PSA/ A4C/ Scand IVC)
  • Focussed questions looking for pathology
  • Limitations
  • Colour/Doppler not included
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CICM GUIDELINE- FOCUSSED QUESTIONS

  • 1. Is the LV significantly impaired?
  • 2. Is the LV dilated?
  • 3. Is the RV function grossly abnormal?
  • 4. Is the RV dilated?
  • 5. Is there any pericardial fluid/tamponade?
  • 6. Is the patient significantly hypovolaemic?
  • 7. Conclusion addressing relevant clinical question
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SHOCK ALGORITHM

  • Assess volume status exclude hypovolaemia
  • IVC
  • LV EDV
  • Assess contractility of LV exclude LV failure
  • Exclude tamponade
  • Assess right heart function exclude PE
  • Exclude pneumothorax
  • Exclude AAA

……..takes about 3 minutes….

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CARDIAC WINDOWS

  • Parasternal
  • Long axis
  • Short Axis
  • Apical
  • 4 chamber
  • 2 chamber
  • Subcostal
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PROBE POSITION

  • Parasternal Long Axis
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PARASTERNAL LONG AXIS

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PARASTERNAL LONG AXIS

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PARSTERNAL SHORT AXIS

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PARASTERNAL SHORT AXIS

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PSAX

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PARASTERNAL SHORT AXIS

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APICAL 4 CHAMBER

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APICAL 4 CHAMBER

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APICAL 4 CHAMBER

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APICAL 2 CHAMBER

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APICAL 2 CHAMBER

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SUBCOSTAL

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SUBCOSTAL VIEW

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SUBCOSTAL

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LV CONTRACTILITY

  • Overview
  • Visual ‘Gestalt’
  • Fractional area change (FAC) (40-60%)
  • Simpsons method
  • Mild impairment EF 50-70%
  • Moderate impairment EF 30-50%
  • Severe impairment EF <30%
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LV CONTRACTILITY- NORMAL

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LV CONTRACTILITY- NORMAL

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LV CONTRACTILITY- NORMAL

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LV CONTRACTILITY- NORMAL

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LV CONTRACTILITY- NORMAL

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SIMPSONS

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SIMPSONS

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THE RIGHT VENTRICLE

  • Shape
  • Size
  • Function
  • Assesment
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VOLUME AND PRESSURE OVERLOAD

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RV/LV RATIO- NORMAL (0.6:1)

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CLASSIC SIGNS OF PE

  • Dilated RV
  • Septal flattening
  • Impaired RV
  • Tricuspid regurgitation
  • McConnels sign
  • Raised PA pressures (RVSP)
  • Visible clot
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SEPTAL FLATTENING

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SEPTAL FLATTENING

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SEPTAL FLATTENING

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VOLUME STATUS- IVC

  • IVC
  • Abdominal probe
  • Sub-costal view- longitudinal
  • Using liver as a window
  • Measure IVC 2cm distal to diaphragm
  • Collapsibility with respiration
  • Visual gestalt
  • M-mode
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IVC DIAMETER AND CVP

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IVC

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IVC

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IVC ANALYSIS

  • Absolute diameter
  • <1cm Correlates with a CVP ~ <5cm H20
  • 1-2cm Correlates with a CVP ~ 5-15cm H20
  • >2cm correlates with a CVP ~ >15cm H20
  • Variability
  • Ventilated patient
  • >12% collapsibility indicates volume responsiveness
  • Unventilated patient
  • >50% collapsibility indicates volume responsiveness
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VOLUME STATUS-IVC

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VOLUME STATUS

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LVEDA NORMAL 12-16 CM

2

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LVEDA

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‘KISSING’ PAPILLARY MUSCLES

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PERICARDIAL EFFUSION AND TAMPONADE

  • Is there a pericardial effusion/collection?
  • <10mm

Small

  • 10-20mm

Moderate

  • >20mm

Large

  • Is there evidence of tamponade?
  • Hypotension
  • RA or RV free wall collapse
  • Dilated IVC
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WHERE THINGS ARE HEADING

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THE FUTURE

  • Portable wireless probes
  • Formal basic ECHO training and examinations in CICM
  • Advanced ECHO clinician in every ICU
  • In-house credentialling and CME
  • TOE and disposable probes
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What the intensivist should know…

ECHOCARDIOGRAPHY