Use of BUS (bedside Ultrasound) to guide forearm fracture reduction
BEDSIDE CARDIAC ULTRASOUND - UCSF CME · 5/28/10 1 BEDSIDE CARDIAC ULTRASOUND Martine Sargent, MD...
Transcript of BEDSIDE CARDIAC ULTRASOUND - UCSF CME · 5/28/10 1 BEDSIDE CARDIAC ULTRASOUND Martine Sargent, MD...
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BEDSIDE CARDIAC ULTRASOUND
Martine Sargent, MD Ultrasound Director, San Francisco General Hospital
Assistant Clinical Professor UCSF Department of Emergency Medicine
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Overview
• Why, Who, What, How of ED Ultrasound...
• How to of Focused Cardiac Examination
• Difficulties & Troubleshooting
• Cases demonstrating pathology
• Literature (briefly!)
Why? - Indications
• Unexplained Dyspnea
• Chest Trauma
• Chest Pain
• Cardiac Arrest
• Unexplained Hypotension
• Procedures
ACEP. Emergency Ultrasound Imaging Criteria Compendium. Ann Em Med. 2006. Oct 49(4): 487-510.
Who? - ED Physicians
• Limited Examination - yes/no questions
• Integrated Bedside Assessment
• Code Management
• Facilitate Interventions/Procedures
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What? - to look for • Pericardial Fluid
• Pericardial Tamponade
• Global Cardiac Function
• Cardiac Activity
• Hyperdynamic/Hypovolemia
• Needle location, capture, success
How? - �Technique
Probe Selection: -Microconvex or phased array probe -3-5 MHz probe Cardiac Setting
How? - Cardiac Views
1. Subxiphoid/Subcostal
2. Parasternal Long Axis
3. Parasternal Short Axis
4. Apical Four Chamber
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How? - Cardiac Views
• Subxiphoid/Subcostal
• Parasternal Long Axis
• Parasternal Short Axis
• Apical Four Chamber
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Exam
• Subxyphoid
• Parasternal long axis
• Parasternal short axis
• Apical 4 chamber view
Educational media courtesy of Mobile Medical Media and the SonoSite Corporation
Subxiphoid
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Subxiphoid
Subxiphoid
• “FAST” view
• Probe under ribs
• Indicator to pt RIGHT shoulder
• Use liver as acoustic window
RV
LV RA
LA
Liver
Text
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TOO SHALLOW GASTRIC BUBBLE
Parasternal Long
Parasternal long
LV
RV
RV
LVOT
LA MV
AV
MV
AV
Chordae
Papillae
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Parasternal Long Axis
• Probe at Left Sternal Border
• 3rd - 5th intercostal space
• Indicator to RIGHT shoulder
• Long axis view of heart
LV
RV Mitral Valve Aortic Valve
Ao
Pericardium
Text
Parasternal Long
• PS views best for estimating EF
• Visualize mitral & aortic valves
Mark D, Ku B, Dean A, et. al. Directed bedside transthoracic echocardiography: preferred cardiac window for left ventricular ejection fraction estimation in critically ill patients. Am J. Emerg Med 2007; 25, 894-900.
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Parasternal Short
PSSA
Parasternal Short
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Parasternal Short Axis
• Left sternal border
• 90o counterclockwise to Long Axis view
• Indicator to RIGHT HIP
• PS views best for estimating LVEF
• Text LV
RV Septum
PSSA - aortic valve
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PSSA - Aortic Valve
• Aortic valve near base
• Mitral valve at annulus
• LV toward apex
Apical 4 approach
3D image courtesy of Yale
At PMI 5th ICS
under nipple marker R
Apical 4 chamber
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Apical 4 • From Apex to
the base
• Visualizes all 4 chambers side-by-side
• relative chamber size
• Best septal view
LV
RV
RA LA
Text
Troubleshooting
• Pulmonary Hyperinflation - COPD, Ventilation
• Poor Parasternal windows
• Favor Apical & Subxiphoid
• Obese, Pregnant, Abd Pain
• Favor Parasternal windows
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CASE of Dyspnea
• 42 yo female presents to the ED with 2 weeks of increasing shortness of breath.
• Vital signs are BP 118/82, P 104, RR 24, T 37.6, SaO2 97%RA.
• CXR shows:
Text
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Pericardial Effusion
• Reduced time to diagnosis
• Suggested by CXR finding of enlarged cardaic silhouette
• Traumatic, Uremic, Malignant, Infectious
• Fake out of epicardial fat
• Ranges from benign to tamponade
Pericardial Effusion
• Dark stripe between pericardium & myocardium
• Dependent area more sensitive & specific
short-axis: effusion
• Doughnut Shaped
• Anechoic Stripe
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Mandavia et al. Ann Em Med (2001) 38(4) 377-382
short-axis: effusion Text
PITFALLS & fakeouts:
Fakeouts of Pleural or Abdominal cavity fluid
Fat will move together with heart
Beware non-dependent collections Beware of clotted blood/loculations Myocardial reflections
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Case of Blunt Trauma
• 27 yo male BIB medics as trauma S/P running his car into a tree in a suicide attempt. Pt’s mental status deteriorates in the trauma bay and goes into PEA.
• Bedside ultrasound shows:
Pericardial Tamponade
Pericardial Tamponade
• Acute Chest Trauma
• Large Chronic Effusion
• Expanding Effusion
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Tamponade Systolic collapse of RA, Diastolic collapse RV
Penetrating Chest
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Standstill
Trauma Resucitation
• Yes/No - Cardiac Activity
• Yes/No - Effusion/Tamponade
• Reduce time to OR or intervention
CASE of chest pain
• 62 yo female presents to the ED with chest pain for 6 hours. She is becoming nauseous and diaphoretic.
• Vital signs are BP 89/46, HR 109, RR 16, T 36.9. CXR shows:
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Ejection Fraction
• 115 patients ED vs. Formal echo
• Poor <30%, Moderate 30-55%, Normal >55%
• Concordance 86%
3Randazzo M, Snoey E, et al. Accuracy of Emergency Physician Assessment of Left Ventricular Ejection Fraction and Central Venous Pressure Using Echocardiogram. Acad Emerg Med. 2003; 10: 973-977.
EF- Normal Text
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EF - LOW Text
Ejection Fraction
• Parasternal Short Axis View
• How well does the heart move?
Code Management • Yes/No - Cardiac Activity?
• Yes/No - Continue Resucitation?
• PEA, No motion = 100% PPV Death
• May Elucidate Reversible Causes
• Effusion/Tamponade
• Evidence of PE/RV collapse
• 2Blaivas M, Fox JC. Outcome in Cardiac Arrest Patients Found to Have Cardiac Standstill on the Bedside Emergency Department Echocardiogram. Acad Emerg Med. 2001; 8: 616-621.
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Text
PEA
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Standstill/Effusion�
Hypotension Management
• Is patient dry?
• Assess IVC for volume status
• Hyperdynamic heart may indicate hypovolemia, sepsis
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Finding IVC
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IVC - Normal
Plethora
CASE of Hypotension
• 36 yo male with h/o nephrotic syndrome presents to the ED with chest pain & SOB. He is anxious nauseous and diaphoretic.
• Vital signs are BP 92/60, HR 118, RR 28, T 36.9, O2 Sat 95%.
• CXR shows:
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Plethora Text
Text
Pulmonary Embolus
• PE & Shock = Thrombolytics
• Best view = Apical 4 chamber
• RV dilatation
• IVC Plethora
• Abnormal Septum
Text
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Interventions
• Pericardiocentesis
• Transvenous Pacer Insertion
• Trancutaneous & Transvenous Pacer Capture
Summary
• Why? Remember Clinical Indications
• Why? Case Management, Facilitate Interventions & Procedures
• Who? ED docs
• What? Yes/No Questions
• How? 4 Views
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Exam
• Subxyphoid
• Parasternal long axis
• Parasternal short axis
• Apical 4 chamber view
Educational media courtesy of Mobile Medical Media and the SonoSite Corporation
Questions Questions Questions Questions Questions Questions Questions Questions Questions Questions Questions ?
References • ACEP. Emergency Ultrasound Imaging Criteria Compendium. Ann Em Med. 2006. Oct 49(4): 487-510.
• Mark D, Ku B, Dean A, et. al. Directed bedside transthoracic echocardiography: preferred cardiac window for left ventricular ejection fraction estimation in critically ill patients. Am J. Emerg Med 2007; 25, 894-900.
• Blaivas M, et al. Potential Errors in the Diagnosis of Pericardial Effusion on Trauma Ultrasound for Penetrating Injuries. 11/2000. 1261-1266.
• Blaivas M, Fox JC. Outcome in Cardiac Arrest Patients Found to Have Cardiac Standstill on the Bedside Emergency Department Echocardiogram. Acad Emerg Med. 2001; 8: 616-621.
• Randazzo M, Snoey E, et al. Accuracy of Emergency Physician Assessment of Left Ventricular Ejection Fraction and Central Venous Pressure Using Echocardiogram. Acad Emerg Med. 2003; 10: 973-977.
• Salen P, Melnicker L, Chooljian C, Et.Al: Does the Presence or Absence of SIonographically Identified Cardiac Activity Predict Resucitation Outcomes of Cardiac Arrest Patients? Am J. Emerg Med 2005; V3: 459-462.
• Sierzenski PR, et al. Emergency Physician Echocardiography Decreases Time to Diagnosis of Pericardial Effusions. Acad Emerg Med. 2003; 10: 561-562.
• Tayal VS, Moore CL, Rose GA. Emergency Ultrasound. Chapter 5: Cardiac. Ma & Mateer. 2003. McGraw Hill.
• Mandavia, et al. Bedside Echocardiography by Emergency Physician. Annals of EM; 10/2001;377-382