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Cardiac UltrasoundJustin A Davis, MD MPH RDMS
Subchief for Emergency UltrasoundKaiser Permanente East Bay Medical Center
Disclosures
• I have nothing to disclose.
Introductory Case
80 y/o maleSyncope at home
Emesis x 3 in ambulanceLooks sick.
No pain.
Talking fine
Clear LungsNo murmurs
Pulses weak
No Edema
HR 118 BP 65/43 RR 27 O2 99%
Soft, non-tenderNo pulsatile Mass
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Distal Aorta
Transverse
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 ProvidedBy Bedside Ultrasound
• Pericardial Effusion
• Cardiac Function
• Central Venous Pressure
The Basics:
Applications
• Trauma
• Cardiac Arrest
• Hypotension
• Chest Pain
Cardiac FunctionEffusion
PericardialEffusion
Central VenousCentral VenousPressure
• 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 ptsRIGHT
• IndicatorScreenLEFT
General Radiology/EM Cardiology
Controversy:
• Scan from ptsLEFT
• IndicatorScreenRIGHT
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 IndicatorToward right shoulder
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Long Axis
Short Axis
Cardiac Planes
LVLV
RVRV
AoAo
DTADTA
LALA
Long Axis Plane
LVLVRVRV
Parasternal Long Axis View
LVLV
RVRV
Ao
DTA
MitralValve 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 CCWfrom Long Axis
Short Axis Plane
LVLV
RVRV
Chest Wall
Back
ViewParasternal Short Axis
ViewTips:•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 ViewIndicator similar to Short
Axis, Perpendicular plane
4 Chamber Plane
LVLV
RVRV
LALA
RARA
ApicalWindow
4 Chamber Plane
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LVLVRVRV
LALARARA
Apical 4 Chamber View
Apical 4 Chamber View
•Tips:• Left lateral decubitus
• End-expiratory hold
• Under the breast fold
• Aim sound wavestoward right scapula
Subxiphoid 4 Chamber View
LVLA
RVRA
Subxiphoid 4 Chamber View
Liver
LV
LA
RV
RA
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Liver
RA
RV
LALALVLV
Subxiphoid4 Chamber View
•Tips:• Firm pressure
• Inspiratory hold
• Bowel Gas? Try right of midline
Subxiphoid 4 Chamber View
IVCIVC
Indicator toward chinAim towards thoracic
spine
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IVC
RA
IVC
IVCImage the
IVC entering Right Atrium
• Assess for IVC fullness
• Assess % collapse with spontaneous inspiration
• Just inferior to hepatic vein junction
IVCGoals
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
SpineAortaIVC
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 EffusionsParasternal Long Axis
Pericardial EffusionsSubxiphoid 4 Chamber
Pericardial EffusionsFalse Positives
• Epicardial fat pad
• Left pleural effusion
• Ascites
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False Positive: Fat Pad
Pericardial EffusionsFalse 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 EffusionsFalse 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
PericardialEffusion
False Positive: L Pleural Effusion
False Positive: L Pleural Effusion
False Positive: L Pleural Effusion
False Positive: L Pleural Effusion
Use FAST LUQview to confirm
False Positive: Ascites
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Pericardial EffusionsFalse Positive: Ascites
• Only seen in subxiphoid view
• Will often disappear with deep inspiration
• Confirm ascites in abdominal views
Pericardial EffusionsFalse Negative: Blood
Clot• Clotting blood can appear from
anechoic to hyperechoic, to mixed.
• Look for your landmarks
• Check multiple views
False Negative: ClotOutline
• 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 axisImage 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
MitralValve
LV Function
STANDSTILLSTANDSTILL
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LV Function
AgonalAgonal
LV Function
Severely DepressedSeverely Depressed
LV Function
Moderately DepressedModerately Depressed
LV Function
Moderately DepressedModerately Depressed
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LV Function
NormalNormal
LV Function
HyperdynamicHyperdynamic
Outline
• Information Gained and its Applications
• Cardiac Anatomy & Image Acquisition
• The Basics: Effusions, Function, IVC
• Advanced: Tamponade, RV Strain, Aortic Root Dilation
IVC and CVPIVC 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 CVPIVC
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 CVPM-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:TamponadeImpending
(Clinical Diagnosis)
What does RA or RV collapse look like?
RA Diastolic CollapseSeen in 75%
•
RV Diastolic CollapseSeen 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 - ModeRV Collapse
RV Free Wall
Ant. Mitral Valve
RV wall moving inward while mitral valve is
open
Pulsus ParadoxusPulsed 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”-ShapedLeft 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 ChamberNormal
Need to image both tricuspid and mitral valves well to comment on RV:LV ratioNeed 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 on 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 FindingDilated Aortic Root
• 90% of Ascending aortic dissection have dilated ascending aorta (>4cm)
• Parasternal long axisand 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/NoCircumferential hypoechoic fluid displaced by heart motion
• LV Function: Gestalt estimateNote LV contraction and Anterior Mitral Valve leaflet approaching the septum
• IVC: Gestalt CVP estimationNote IVC size and collapse with respiration
Bedside EchoSummary
• Advanced Findings:
• Impending Tamponade:Large effusion, plethoric IVC, +/- RA/RV collapse
• RV Strain:RV appears enlarged and poorly contractingLV is D-shaped on short axis
• Aortic Root Dilation:High parasternal long axis, normal <4cm
Bedside EchoSummary