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Emergency Medicine
Liver as acoustic
window
Alternative to
apical 4 chamber
view
Subcostal View
Subcostal View
Subcostal View
Angle probe right to
see IVC
Response of IVC to
sniff indicates central
venous pressure
No collapse
– Tamponade
– CHF
– PE
– Pneumothorax
Parasternal Views
Next best imaging window
Good for imaging LV
Comparing chamber sizes
Localized effusions
Differentiating pericardial from pleural
effusions
Parasternal Long Axis
Near sternum
3rd or 4th left intercostal space
Marker pointed to patient’s right
shoulder (or left hip if screen is not
reversed for cardiac imaging)
Rotate enough to elongate cardiac
chambers
Parasternal Long Axis
Parasternal Long Axis View
Parasternal Short Axis
Obtained by 90° clockwise rotation
of the probe towards the left
shoulder (or right hip)
Pericardial Effusion
Case Presentation
45 year old male presents with SOB
and dizziness for 2 days. He has a long
smoking history, and has complained of
a non-productive cough for “weeks”
Initial VS are BP 88/palp, HR 140
PE: Neck veins are distended
Chest: Clear, muffled heart sounds
Bedside sonography was performed
Echo free space around the heart
Pericardial effusion
Pleural effusion
Epicardial fat (posterior and/or
anterior)
Less common causes:
– Aortic aneurysm
– Pericardial cyst
– Dilated pulmonary artery
Size of the Pericardial
Effusion
Not Precise
Small: confined to posterior space,
< 0.5cm
Moderate: anterior and posterior,
0.5-2cm (diastole)
Large: > 2cm
Pericardial Fluid: Subcostal
Clinical features of
Pericardial effusion
Pericardial fluid accumulation may
be clinically silent
Symptoms are due to:
– mechanical compression of adjacent
structures
– Increased intrapericardial pressure
Pericardial
Effusion:Asymptomatic
Up to 40% of pregnant women
Chronic hemodialysis patients
– one study showed 11% incidence of
pericardial effusion
AIDS
CHF
Hypoproteinemic states
Symptoms of Pericardial
Effusion
Chest discomfort (most common)
Large effusions:
– Dyspnea
– Cough
– Fatigue
– Hiccups
– Hoarseness
– Nausea and abdominal fullness
Cardiac Tamponade
Increased intracardiac pressures
Hypocontractile
walls
Hypovolemia
Small chamber filling size
Aggressive wall motion
Flat IVC or exaggerated collapse
with deep inspiration
Massive PE or RV infarct
Dilated Right
ventricle
RV hypokinesis
Normal Left
ventricle function
Stiff IVC
Case presentation ? overdose
27 yo f brought in with “passing out”
after night of heavy drinking.
Complaining of inability to breathe!
PE: Obese f BP 88/60 HR 123 Ox
78%
Chest: clear
Ext: No edema
Bedside sonography was performed
Chest pain then code
55 yo male suffered witnessed Vfib
arrest in the ED
ALS protocol - restoration of perfusing
rhythm
Persistant hypotension
ED ECHO was performed
R sided leads
Non Traumatic
Resuscitation
Direct Visualization
Is there effective myocardial
contractility?
– Asystole
– Myocardial “twitch”
– Hypokinesis
– Normal
Is there a pericardial effusion?
ECHO in PEA
Perform ECHO during “quick look”
and in pulse checks
Change management based on
“positive” findings
Pericardial tamponade
– Pericardiocentesis
Hyperdynamic cardiac wall motion
– Volume resuscitate
ECHO in PEA
RV dilatation
– Hypoxic?? – Likely PE
– ECG – IMI with RV infarct?
Profound hypokinesis
– Inotropic support
Asystole
– Follow ACLS protocols (for now)
– Early data suggesting poor prognosis
ECHO in PEA
False positive cardiac motion
– Transthoracic pacemaker
Pericardiocentesis
No pericardial/pleural effusion
Pericardial clot
Pericardial fat
Pericardial or Pleural Fluid
Left parasternal long axis:
– Pericardial fluid does not extend posterior
to descending aorta or left atrium
Subcostal:
– No pleural reflection between liver and R
sided chambers
– A pleural effusion will not extend between
to RV free wall and the liver
Pleural and Pericardial fluid
Pleural effusion
Blunt Cardiac Trauma
Cardiac contusion
Cardiac rupture
Valvular disruption
Aortic disruption/dissection
Blunt Cardiac Trauma
Pericardial effusion
Assess for wall motion abnormality
– RV dyskinesis (takes the first hit)
Assess thoracic aorta:
– Hematoma
– Intimal flap
– Abnormal contour
Valvular dysfunction or septal rupture
Cardiac Contusion