Disclosures Cardiac Ultrasound - UCSF CME Davis Echo... · Dilated Aortic Root • 90% of Ascending aortic dissection have dilated ascending aorta (>4cm) • Parasternal long axis

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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





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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


Probe IndicatorToward right shoulder

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Long Axis

Short Axis

Cardiac Planes

LVLV

RVRV

AoAo

DTADTA

LALA

Long Axis Plane

LVLVRVRV


LVLV

RVRV

Ao

DTA

MitralValve Leaflets

•Tips:• Stay close to sternum

• End-expiratory hold

• Difficult in COPD


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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



•Tips:• Left lateral decubitus

• End-expiratory hold

• Under the breast fold

• Aim sound wavestoward right scapula

Subxiphoid 4 Chamber View

LVLA

RVRA


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


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





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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


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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





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





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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





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





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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





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



(Septal Wall Flattening)

Normal



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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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





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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


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


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Outline





• 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

Documents

Disclosures Cardiac Ultrasound - UCSF CME Davis Echo... · Dilated Aortic Root • 90% of Ascending aortic dissection have dilated ascending aorta (>4cm) • Parasternal long axis