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![ACORTAMIENTO DE LA FRACCION CONTRACTIL
• Eje para esternal largo
• Modo M
• Fracción de acortamiento(%) =
[(EDD ESD)/EDD] x 100
• Normal 30-45%
Perera et al. Cardiac Echocardiography Crit Care Clin 30 (2014) 47–92](https://image.slidesharecdn.com/focus-190719052856/85/FOCUS-19-320.jpg)
Subido porAna Angel
FOCUS
Este documento resume el uso del ecocardiograma enfocado (FOCUS) en emergencias, destacando que permite evaluar rápidamente la función cardíaca, espacio pericárdico y volumen intravascular al cabecero del paciente. Explica los objetivos y limitaciones de FOCUS, así como su utilidad para evaluar la contractilidad cardíaca, derrame pericárdico, taponamiento, estado de volumen y más, guiando el diagnóstico y tratamiento en diversos escenarios clínicos como paro cardíaco, shock y trauma torácico.
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FOCUS
- 1. ECOCARDIOGRAMA EN EMERGENCIAS Ana MaríaÁngel Medicina de Emergencias Universidad Icesi
- 2. FoCUS FOCUSED CARDIAC ULTRASOUND •Focused echocardiography • Emergency echocardiography • Bedside limited echocardiography • Point-of-care cardiac ultrasound • Goal-directed echocardiography Manasia AR et al. J Cardiothorac Vasc Anesth.
- 3. INTRODUCCIÓN • Se convirtióen una practica frecuente • A la cabecera del paciente • Evaluación de la función cardiaca, espacio pericárdico y el volumen Iv • Responder a preguntas especificas • Escenario pre hospitalario • Mejora el diagnóstico en aprox 40% cuando se compara con el examen físico convencional Emerg Med J 2009;26:82–86
- 4. • Point ofCare US • Detecta un numero especifico de condiciones cardiacas • No debe reportarse como un examen de ecocardiograma tradicional • Toda anormalidad detectada debe ser referida al Eco TT • Debe ser usado por personal entrenado European Heart Journal. Cardiovascular Imaging 2014:15:956-960
- 5. LIMITACIONES • Imagen demenor calidad comparada con el Eco TT tradicional • Lugares desfavorables para obtener una buena imagen • Limitación de tiempo • Anormalidades cardíacas complejas o difíciles de diagnosticar FOCUS puede omitir hallazgos incidentales del 36 a 45% de los casos European Heart Journal. Cardiovascular Imaging 2014:15:956-960
- 6. European Heart Journal.Cardiovascular Imaging 2014:15:956-960
- 7. DIFERENCIAS ENTRE ELECO TT Y EL FOCUS J Am Soc Echocardiogr 2013;26:567-81. Imágenes adicionales Identificar artefactos y hallazgos incidentales Técnicas cuantitativas Identifica la presencia o ausencia de uno o varios hallazgos usando protocolos
- 8. J Am SocEchocardiogr 2010;23:1225-30.) Importancia del FOCUS en el cuidado del paciente El papel principal de FOCUS es la evaluación en corto tiempo del paciente sintomático. Targets (Metas) y Escenarios Clínicos
- 9. TARGETS Función cardíaca sistólica Dilataciónde VD Estado de volumen Diagnóstico y pericardiocentesisDerrame pericárdico Determinar la FEVI para decidir la mejor intervención Priorizar los estudios para tep y ayudar en el dx diferenciar y asistir en la toma de decisiones para el manejo. Identificar pacientes hipovolémicos
- 10. ESCENARIOS CLÍNICOS Paro cardiaco Shock/hipotensión Disnea Dolor torácico Trauma cardiaco FOCUS es parte del FAST. Disminuye el tiempo del dx y tta de lesiones cardíacas y torácicas Identificar si hay contractilidad organizada, para distinguir entre asistolia o AESP. , determinar el curso del arresto cardíaco, guiar procedimientos Determinar el tipo de shock Descartar derrame pericárdico Identificar disfunción del VI Identificar el tamaño del VD Descartar tep y disección de Ao, taponamiento , derrame pericárdico
- 12. DERRAME PERICARDICO •Incidencia: 13.6%(IC = 8% - 23%) •Buscar en el para-esternal largo y ventana subxifoidea •Diferenciar de ascitis y derrame pleural Incidence of pericardial effusion in patients presenting to the emergency department with unexplained dyspnea. Acad Emerg Med 2001;8(12): 1143–6.
- 13. TAPONAMIENTO • Colapso delVD en diástole • AD hiperdinámica • IVC pletórica sin colapso • Doppler: Aumento de la velocidad mas del 25% en inspiración en la tricúspide • Mitral: disminución 15% durante la inspiración
- 14. COLAPSO DE CAVIDADES Aurículasmas delegas En diástole: presión pericárdica aumenta por el aumento en el volumen Aurículas son comprimidas por la presión elevada intra pericardica, su contenido pasa al ventrículo .
- 15. Circulation 65: 1491,1982 TAPONAMIENTO Circulation. 1983;68:294-301 S: 100% E: 82%; VP: 50%
- 16. lACC Vol 2,No 4 Oct 1983 7 5 ADVD AD diástole E: 95% S: 100% VP 90 %
- 18. EVALUACION DE LACONTRACTILIDAD CARDIACA Función sistólica del VI •Fracción de acortamiento •Separación septal EPSS •Regla de Simpson modificada •Evaluación cualitativa Perera et al. Cardiac Echocardiography Crit Care Clin 30 (2014) 47–92
- 19. ACORTAMIENTO DE LAFRACCION CONTRACTIL • Eje para esternal largo • Modo M • Fracción de acortamiento(%) = [(EDD ESD)/EDD] x 100 • Normal 30-45% Perera et al. Cardiac Echocardiography Crit Care Clin 30 (2014) 47–92
- 20. SEPARACIÓN SEPTAL PUNTOE: EPSS • E-point septal separation (EPSS) • Paraesternal largo--Modo M • Grado de apertura de la Válvula mitral • Mayor de 1 cm= contractilidad disminuida • Limitaciones Perera et al. Cardiac Echocardiography Crit Care Clin 30 (2014) 47–92
- 21. METODO SIMPSON MODIFICADO •Determinación del volumen en 3 dimensiones • Representa el cambio de volumen de VI durante la sístole • FE= Volumen sistólica / Volumen al final de la diástole • Volumen sistólico= Diferencia volumen en diástole y sístole (VFD – VFS) Perera et al. Cardiac Echocardiography Crit Care Clin 30 (2014) 47–92
- 22. MEDICIÓN CUALITATIVA VEF (VisualEstimation fraction) • Evaluación del movimiento de las paredes del VI • Estimación visual del cambio de volumen de la diástole a la sístole 4 categorías: • Hiperdinámico • Normal • Moderadamente disminuida • Severamente disminuida Perera et al. Cardiac Echocardiography Crit Care Clin 30 (2014) 47–92
- 23. LIMITES Y VALORESDE LA FE VI Lang et al Journal of the American Society of Echocardiography 2005.
- 24. Am Heart J.2003; 146:380-2. • 47 estudios- 8 incluyen método subjetivo • Es menos exacto en presencia de FA • Valor límite (Zona gris): 30-50%
- 25. Am Heart J.2003; 146:380-2. 0.71-0.94
- 26. West J EmergMed. 2014;15(2):221–226 Determinar si la estimación visual de la función sistólica del VI por EM (Emergenciologo) se correlaciona con el Nétodo de Simpson calculado por cardiología. 133 pacientes con disnea Concordancia entre cardiólogo y EM: 0.87 (95% CI, 0.82-0.90) Correlación entre los 2 EM: 0.952 (95% CI: 0.934, 0.966).
- 27. International Journal ofCardiology 101 (2005) 209 – 212 ¿Es el método cualitativo de estimación visual (Eyeballing) comparable con otros métodos cuantitativos? 89 pacientes IAM R/ Correlación significativa con otros métodos
- 28. R = 0.857R = 0.898 R = 0.919 Variabilidad intraindividual. International Journal of Cardiology 101 (2005) 209 – 212
- 29. CONTRACTILIDAD CARDIACA YRCCP Hay o no hay actividad cardiaca ? • Asistolia o AESP (PEA) • Algunos pacientes con AESP muestran actividad cardíaca con el US. • Hipovolemia/Tep: Contractilidad miocárdica aumentada • IAM/ metabólicas: hipocinesia • Mal pronóstico si no hay actividad cardíaca con el US. Echocardiography in cardiac arrest. Curr Opin Crit Care. 2010 Resuscitation 2010 Nov;81(11):1527-33
- 30. US EN ARRESTOCARDÍACO • Identificar la causa del paro. • Mejora el manejo
- 33. • PEA yAsistolia • Modo M • Hay o no hay actividad cardÍaca • 70 pacientes : 36 asistolia y 34 PEA No actividad cardíaca No ROSC independientemente si era asistolia o PEA Am J Emerg Med. 2005 Jul;23(4):459-62.
- 34. S:80%-100% E: 66%- 95% AUC: 0.9251
- 35. TRAUMA CARDIACO-TORAX • Rupturaválvulas • Ruptura miocardio • Ruptura grandes vasos • Disección de aorta • Derrame pericárdico • Taponamiento cardíaco Emerg Med J 2009;26:82–86 • Mayor supervivencia en pacientes con actividad cardíaca 23.5% vs 1.9% • Supervivencia a la admisión hospitalaria S:86% E: 91% VPP: 30% VPN: 99% J Trauma Acute Care Surg. 2012
- 36. EMBOLISMO PULMONAR Cardiol Rev.2010 1. Aumento VD o Hipocinesia 2. Función del VD disminuida 3. Movimiento paradójico del septo 4. Aplanamiento del septo IV (Forma en D del VI en el eje corto) 5. Regurgitación tricúspide 6. Hipertensión pulmonar (detectada por Doppler: Regurgitación tricúspide con una velocidad Jet > 2.6 m/s) 7. Signo de Mc Connell: Hipocinesia de la pared libre 8. Trombo AD o VD 9. Hipertrofia del VD 10. Dilatación de la VCI sin colapso inspiratorio 11. Foramen ovale x Hipertensión pulmonar
- 37. LIMITACIONES DEL FOCUSEN TEP • Operador dependiente • Casi nunca se visualiza el trombo • Diagnósticos diferenciales: • Dilatación ventrículo derecho - EPOC - Infarto VD - Cardiomiopatía - Enfermedad vascular Cardiol Rev. 2010
- 38.
- 39. DOLOR TORACICO ENEMERGENCIAS Eur J Emerg Med. 2012
- 41. ESTADO DE VOLEMIA BleharDJ, et al. Am J Emerg Med. 2009
- 42. US DE LAVCI PARA DETERMINAR PVC Metanalisis: 37 artículos, 2843 casos Correlación entre la PVC: IVC dm 0.68 Índice de colapsabilidad 0.44 Alavi-Moghaddam M et al. Ultrasonography of inferior vena cava to determine central venous pressure: a meta-analysis and meta-regression. Acta Radiol. 2016
- 43. Vena Yugular Interna Distenciónyugular para Identificar ICC en pacientes con disnea S: 99% E: 59% Jang T. Am J Emerg Med. 2011
- 44. SIMPLE approach forevaluation of key elements during focused cardiac ultrasound sound (FoCUS) in shock patients
- 46. PROCEDIMIENTOS PERICARDIOCENTESIS Y COLOCACIÓN DEMARCAPASO •Pericardiocentesis guiada por eco 1970 •Cable del marcapaso se visualiza pasando de la AD al VD
- 47.
Notas del editor
- #3 is a focused examination of the cardiovascular system performed by a physician by using ultrasound as an adjunct to the physical examination to recognize specific ultrasonic signs that represent a narrow list of potential diagnoses in specific clinical setting Cardiacechocardiographyallowsfortheimmediatediagnosisofpericardialeffusionsand cardiac tamponade, the evaluation of cardiac contractility and volume status, and the detection of right ventricular strain that may be seen with a significant pulmonary embolus The emergent cardiac procedures, pericardiocentesis and placement of a transvenous pacemaker wire, can be performed more accurately and safely with ultrasound guidance.
- #4 (
- #5 Debe ser usado como US de point of care. Para detectar un numero especifico de condiciones cardiacas Puede dar información clave con respecto a la presencia de derrame pericardico/taponamiento, tamaño y función del VI y VD, volumen intravascular y para toma de decisiones durante la reanimación El focus no debe reportarse como un examen de ecocardiograma tradicional Debe ser usado por personal entrenado Toda anormalidad detectada en el Focus debe ser referida al eco tt Si no se puede establecer el diagnostico o descartar una condición con el Focus se debe solicitar un eco tt Supervisión y control de calidad de los FOCUS
- #9 American Society of Echocardiography (ASE) and the American College of Emergency Physicians (ACEP) delineates the important role of focused cardiac ultrasound (FOCUS) in patient care and treatment and emphasizes the complementary role of FOCUS to that of comprehensive echocardiography. We outline the clinical applications where FOCUS could be used, as part of the evolving relationship between echocardiography laboratories and emer- gency departments. Although cardiac ultrasound as performed by emergency physicians in emergency departments is often performed in the context of other focused ultrasound applications (examining the hypotensive patient for abdominal aortic aneurysms, ruptured
- #10 he principal role for FOCUS is the time-sensitive assessment of the symptomatic patient. This evaluation primarily includes the assessment for pericardial effusion and the evaluation of relative chamber size, global cardiac function, and patient volume status Other pathologic diagnoses (intracardiac masses, LV thrombus, valvular dysfunction, regional wall motion abnormalities, endocarditis, aortic dissection) may be suspected on FOCUS, but additional evaluation, including referral for comprehensive echocardiography or cardiology consultation, is recommended. Further hemodynamic assessment of intracardiac pressures, valvular pathology, and diastolic function requires additional training in comprehensive echocardiogra- phy techniques.
- #11 True PEA is defined as the clinical absence of ventricular contraction despite the presence of electrical activity, whereas pseudo-PEA is defined as the presence of ventricular contractility visualized on cardiac ultrasound in a patient without palpable pulses.32,34,35 Therefore, making the diagnosis of pseudo-PEA can be of diagnostic and prognostic importance. Patients with pseudo-PEA have some observable, although minimal, cardiac output and have a higher survival rate, in part because there are often identifiable and treatable causes of their arrest.32-35,37,38 Although there is ample literature to support that causes of PEA and pseudo-PEA can be identified with FOCUS (see ‘‘Hypotension/Shock’’ section), research is now focused on patient outcomes. Identification of causes of PEA arrest by FOCUS with zero or minimal interruption in cardiopulmonary resuscitation improves outcomes by decreasing time to treatment and to return of spontaneous circulation.32-35 FOCUS is only recommended in PEA and asystolic rhythms and should not delay lifesaving treatment of ventricular arrhythmias. These patients should be stabilized, and a comprehensive echocardiogram, looking for potential specific structural abnormalities such as hypertrophic cardiomyopathy or RV dysplasia, can be performed at a later point.33
- #13 Published studies have documented that pericardial effusions may be encountered relatively commonly in critical patients with acute shortness of breath, res- piratory failure, shock, and cardiac arrest.21,22 Fortunately, the literature also suggests that EPs with focused echocardiographic training can accurately identify effusions.23
- #15 Figure 3, Two-dimen sional echocardiogram in the apical four chamber view. A, End-systolic frame. B, End-diastolic frame. Note marked diastolic right atrial compression creating a slit-like cavity (ar rows). The right ventricle is also compressed. Abbreviations as in Figure 2. Mecanismo of atrial compression and abnormal wall motion in tamponade. In this report , diastolic compression of both atria is suggested as an echocardiographic sign of cardiac tamponade. The atrial walls are thinner and are therefore more readily compre ssed than those of the ventricles. During diastole, the pericardial pressure increases as a consequence of an increase in cardiac volume . Thethin-walled atria are compressed by the elevated intrapericardial pressure, their contents being expelled into the ventricles or their respective venous connections. The resulting increase in diastolic atrial pressures is probably the cause of the diminished y descent that is seen in tamponade Figure 2. Two-dimensional echocardiogram In the apical four chamber view ofa patient with cardiac tamponade . A,End-systolic frame . B, End-diastolic frame . Note the diastolic compression of both atria (arrows). E=pericardial effusion; RA =TIght atrium; other abbreviations as in Figure 1.
- #16 1982 The value of a newly described echocardiographic sign for the detection of cardiac tamponade was retrospectively evaluated in 91 patients. M-mode echocardiograms were reviewed in 86 patients, 36 of whom had concurrent two-dimensional echocardiographic examinations; in five patients, only two-dimensional echocardiography was performed. Cardiac tamponade was clinically present in 17 patients, 14 of whom had abnormal posterior motion of the right ventricular free wall in early diastole. Two of the 17 patients with tamponade had equivocally abnormal motion and one had normal wall motion. The patient with normal wall motion was later proved to have predominantly constrictive pericardial disease. In all cases, the abnormal wall motion reverted to normal after a definitive drainage procedure. Two-dimensional echocardiography confirmed that the abnormal right ventricular wall motion represented a true collapse of the right ventricular cavity in early diastole. Of the 69 patients without clinical cardiac tamponade, only seven had abnormal right ventricular wall motion. Detection of abnormal diastolic right ventricular free wall motion may be a sensitive indicator of a hemodynamically significant pericardial effusion. Conversely, the presence of normal motion of the right ventricular free wall appears to be a reliable indicator that the pericardial effusion is exerting little effect on overall cardiac function. Hydrodynamic compression of RA 127 derrame pericárdico Taponamiento en 19 pacientes La inversión de la Aurícula Derecha se presento en 19:19 FIGURE 3. Apical four-chamber cross-sectional echocardiogram demonstrating riaht atrial inersion (RAI). In early systole (left) the right atrial tree wall (RAFW) is strikingly inverted. Bv end-systole (right) the right atrium (RA) has filled and the RAFW contour is normally rounded In summary, right atrial inversion is an extremely sensitive marker of cardiac tamponade. Its specificity and predictive value may be significantly enhanced without loss of sensitivity by consideration of the duration of right atrial inversion. Thus, prolonged right atrial inversion is strongly suggestive of cardiac tamponade, and transient inversion is unlikely to be associated with severe hemodynamic compromise. The degree of inversion, however, does not appear to discriminate between those patients with and those without cardiac tamponade.
- #17 Nine patients with clinical and hemodynamic evidence of cardiac tamponade underwent M-mode and two-dimensional echocardiography. Pericardial effusion was documented in each patient. Four patients demonstrated respiratory variation in ventricular volumes in association with paradoxical pulse. Right ventricular compression was present in seven. In five patients, echocardiography demonstrated diastolic left atrial compression. In all nine patients, the apical four chamber view revealed diastolic right atrial compression. Drainage of 450 to 1,800 cc of pericardial fluid relieved the cardiac tamponade and eliminated the echocardiographic findings associated with this disorder. These observations suggest that the echocardiographic finding of atrial compression is a sensitive sign of cardiac tamponade.
- #20 Note that an M-mode tracing in a normal heart will show the left ventricular walls almost touching completely during systole with a high frac- tional shortening In a poorly contracting heart, the M-mode tracing demonstrates wide systolic sep- aration between the ventricular walls and a low fractional shortening (Fig. 25). Remember that estimating fractional shortening is a quick and easy way to estimate systolic function at the bedside, and should be used in conjunction will the entire clinical picture.
- #21 ith normal contractility, the anterior mitral leaflet should touch the septum during diastole. The distance separating the anterior mitral leaflet and the septum can be easily evaluated in M-mode The taller first wave is the E-wave, which reflects the initial opening of the mitral valve to allow passive filling of the left ventricle. The smaller, second wave is the A-wave, which corresponds to left atrial contraction at the end of diastole.18 As cardiac contractility decreases, EPSS increases. Studies have shown that an EPSS greater than 1 cm correlates with a generally low ejection fraction Normal E-point septal separation (EPSS) where the anterior mitral valve touches the septum during diastole. A, left atrial contraction; E, initial opening of mitral valve; IVS, inter- ventricular septum.
- #22 his value represents the volume change of the left ventricle during systole. It is best measured by the biplane method of discs, known as Simpson’s modified rule, using the concept that the left ventricle represents a bullet-shaped structure.49 Using this method, the endocardial borders of the left ventricle are traced in 2 orthogonal views during end-diastole and end-systole, generally from the apical 4-chamber and 2-cham- ber views (Fig. 48). Calculation software can then generate the multiple discs repre- senting the left ventricle, and will sum the calculated volumes to provide an accurate ventricular volume. First, the stroke volume is calculated as the difference between the diastolic and systolic volumetric measurements. Next, ejection fraction is calcu- lated using the equation. As this measurement is relatively complex and time intensive, it is not currently a routine part of the goal-directed echocardiography evaluation.
- #23 The examination focuses on evaluating motion of the left ventricular walls by a visual estimation of the volume change from diastole to systole.39 A ventricle that has good contractility will have a large volume change between the 2 cycles, whereas a poorly contracting heart will have a small percentage change (Figs. 43 and 44). The poorly contracting heart may also be dilated in size. Based on these assessments, a patient’s contractility can be broadly categorized as being normal, mild to moderately decreased, or severely decreased. A fourth category, known as hyperdynamic, dem- onstrates small chambers and vigorous, hyperkinetic contractions with the endocar- dial walls almost touching during systole, often seen as a compensatory response in distributive shock or hypovolemic states.
- #25 contrast ventriculography (CVG) and radionuclide ventriculography (RNVG). WMI/score. A WMI is a mean score of wall motion derived from values of regional wall motion assigned in a segmental LV model. WMI and subjective visual assessment are applicable in the majority of subjects and are likely to be more accurate than Simpson’s rule in subjects who are poorly echogenic or with RWMA. They are also likely to be less accurate in the presence of atrial fibrillation. range 30% to 50%, the evidence indicates that the echocardiogram cannot reliably determine where the true value lies. Therefore we suggest that these cases be classified as ’borderline.’ Clearly, if echocardiography is used alone, ’borderline dysfunction’ would be taken as 40% and ’borderline normal’ as 40%.
- #26 contrast ventriculography (CVG) and radionuclide ventriculography (RNVG). WMI/score. A WMI is a mean score of wall motion derived from values of regional wall motion assigned in a segmental LV model. WMI and subjective visual assessment are applicable in the majority of subjects and are likely to be more accurate than Simpson’s rule in subjects who are poorly echogenic or with RWMA. They are also likely to be less accurate in the presence of atrial fibrillation. range 30% to 50%, the evidence indicates that the echocardiogram cannot reliably determine where the true value lies. Therefore we suggest that these cases be classified as ’borderline.’ Clearly, if echocardiography is used alone, ’borderline dysfunction’ would be taken as 40% and ’borderline normal’ as 40%.
- #27 For this study, the highest agreement was found in the low EF group, and there were 8 patients with normal EF who were diagnosed as low EF by EPs.
- #28 impson ejection fraction, wall motion score index, atrioventricular (AV) plane displacement and fractional shortening are all established formal echocardiographic methods for the assessment of left ventricular systolic function. Visually estimated (eyeballing) ejection fraction may be considered somewhat more subjective, although shown to correlate well with radionuclide ventriculography. We aimed to explore if echocardiographic eyeballing ejection fraction is comparable to formal methods for the evaluation of left ventricular systolic function. Methods: We assessed 89 consecutive patients after myocardial infarction or before coronary angiography. Eyeballing ejection fraction and wall motion score index were evaluated in the long-axis, short-axis and apical four- and two-chamber views. Simpson ejection fraction and AV plane displacement were assessed in the apical views. Fractional shortening was measured in the parasternal long- axis view. The respective systolic function measurements were in each patient made at different time points by a single investigator, masked to prior results. Results: All formal methods correlated significantly with eyeballing ejection fraction ( p < 0.001): AV plane displacement, R = 0.647; FS, R = 0.684; four-chamber Simpson ejection fraction, R = 0.857; biplane Simpson ejection fraction, R = 0.898; and wall motion score index, R = 0.919. Conclusion: Eyeballing ejection fraction correlated closely with all formal methods and the correlation coefficient improved with the reliability of the formal method. This finding is in concordance with prior studies, indicating that eyeballing ejection fraction may be the most accurate echocardiographic method for the assessment of left ventricular systolic function. Since it is readily and quickly performed, eyeballing ejection fraction could be used for routine echocardiography instead of formal methods. D 2004 Elsevier Ireland Ltd. All rights reserved.
- #29 . (A) Correlation plot: eyeballing ejection fraction versus fourchamber Simpson ejection fraction (R = 0.857). (B) Correlation plot: eyeballing ejection fraction versus biplane Simpson ejection fraction (R = 0.898). (C) Correlation plot: eyeballing ejection fraction versus wall motion score index (R = 0.919)
- #30 Cardiac arrest The purpose of pulse assessment during cardiac arrest is to detect the presence or absence of underlying cardiac activity. In the absence of a pulse the emergency physician assumes that the patient has either asystole if the monitor shows no discernible rhythm, or pulseless electrical activity (PEA) if a cardiac rhythm is present. The increased use of ultrasound in these situations has revealed that many patients assumed to have PEA have some degree of cardiac activity.6 This activity ranges from vigorous myocardial contractility in severe hypovolaemia or massive pulmonary embolism to diffusely hypokinetic contrac- tions in massive myocardial infarction or severe metabolic bnormalities. Studies have shown that those cases with cardiac standstill have an almost universally poor prognosis.24–26 One small study identified 27% of those patients with sonographic evidence of cardiac activity surviving to hospital admission, suggesting that echocardiography during cardiac arrest is a useful tool in differentiating those patients with a potentially reversible cause from those with an irreversible cause.25 A possible algorithm for the use of emergency medicine bedside ultrasound in the management of PEA has been produced.27
- #31 Identifying the underlying cause of cardiac arrest represents the one of the greatest challenges of managing patients with asystole or PEA and accurate determination has the potential to improve management by guiding therapeutic decisions.These include cardiac tamponade, severe hypovolemia, pulmonary embolus, tension pneumothorax, and true asystole.
- #32 C.A.U.S.E. is a new approach developed by the authors. The C.A.U.S.E. protocol addresses four leading causes of cardiac arrest and achieves this by using two sonographic perspec- tives of the thorax; a four-chamber view of the heart and pericardium and anteromedial views of the lung and pleura at the level of the second intercostal space at the midclavic- ular line bilaterally. The four-chamber view of the heart and pericardium is attained using either the subcostal, paraster- nal or apical thoracic windows. This allows the individual performing the examination to select the most adequate view depending on the patients’ anatomy.
- #34 This study evaluated the ability of cardiac sonography performed by emergency physicians to predict resuscitation outcomes of cardiac arrest patients. A convenience sample of cardiac arrest patients prospectively underwent bedside cardiac sonography at 4 emergency medicine residency-affiliated EDs as part of the Sonography Outcomes Assessment Program. Cardiac arrest patients in pulseless electrical activity (PEA) and asystole underwent transthoracic cardiac ultrasound B-mode examinations during their resuscitations to assess for the presence or absence of cardiac kinetic activity. Several end points were analyzed as potential predictors of resuscitations: presenting cardiac rhythms, the presence of sonographically detected cardiac activity, prehospital resuscitation time intervals, and ED resuscitation time intervals. Of 70 enrolled subjects, 36 were in asystole and 34 in PEA. Patients presenting without evidence of cardiac kinetic activity did not have return of spontaneous circulation (ROSC) regardless of their cardiac rhythm, asystole, or PEA. Of the 34 subjects presenting with PEA, 11 had sonographic evidence of cardiac kinetic activity, 8 had ROSC with subsequent admission to the hospital, and 1 had survived to hospital discharge with scores of 1 on the Glasgow-Pittsburgh Cerebral Performance scale and 1 in the Overall Performance category. The presence of sonographically identified cardiac kinetic motion was associated with ROSC. Time interval durations of cardiac resuscitative efforts in the prehospital environment and in the ED were not accurate predictors of ROSC for this cohort. Cardiac kinetic activity, or lack thereof, identified by transthoracic B-mode ultrasound may aid physicians' decision making regarding the care of cardiac arrest patients with PEA or asystole.
- #36 Potential complications of trauma to the thorax include rupture of the valves, myocardium and great vessels. Echocardiography is effective in identifying significant cardiac injury.28 If aortic dissection is suspected, transthoracic echocardiography is useful as a rule-in investigation, but if the practitioner has a strong suspicion of pathology, further investigations are required when the portable examination is negative due to the insensitivity of the examination.29 If pericardial effusion/haemopericardium is suspected, this is usually easily detected with transthoracic echocardiography.14 The altered physiological state of cardiac tamponade is identified by observing right atrial systolic collapse and right ventricular diastolic collapse. The ability to do this requires experience.
- #40 Oct;19(5):277-83. doi: 10.1097/MEJ.0b013e328354729d. The role of urgent transthoracic echocardiography in the evaluation of patients presenting with acute chest pain. Shah BN1, Ahmadvazir S, Pabla JS, Zacharias K, Senior R. Author information Abstract Chest pain is one of the most frequent reasons for presentation to the Emergency Department. The possible causes of chest pain are numerous and diverse, but importantly, several conditions, such as acute coronary syndrome, pulmonary embolism and aortic dissection, require urgent management and, in some cases, may be life-threatening. In such situations, a prompt and accurate diagnosis is vital. Two-dimensional echocardiography is a safe, painless and rapid test that can be performed in the Emergency Department and ensure a correct diagnosis as well as identify other complications and help institute appropriate management strategies swiftly. We review the current indications for urgent echocardiography in this article, with reference to international management guidelines where available, when managing patients with suspected acute coronary syndrome, acute pulmonary embolism, acute aortic dissection, acute pericarditis and trauma. We also discuss the differences between comprehensive and FOcussed Cardiac UltraSound (FOCUS) echocardiography studies, along with the associated quality control and medicolegal implications
- #43 A systematic review and meta-analysis of all published studies in PubMed, Scopus, Web of Knowledge, and Google Scholar were conducted from inception to July 2013. We used the STROBE checklist for quality assessment and meta-regression. 37 arSSassssss Thirty-seven papers with 2843 cases were identified. The correlation coefficients between each one of IVCD, inspiratory IVC (iIVC), IVC collapsibility index (IVCCI), and expiratory IVC (eIVC) with CVP, were 0.68, 0.60, 0.54, and 0.44, respectively. There was no evidence of publication bias (P = 0.28). Based on meta-regression, male gender was an important source of heterogeneity (OR = 1.01; 95% confidence interval, 1-1.03), which resulted in a higher correlation between IVCD and CVP. The present study showed a higher strength of association with CVP pertaining to IVCD, iIVC, IVCCI, and eIVC, respectively, and they were higher in men. CONCLUSION: This study does not support the measurement of IVCD by ultrasonography as an acceptable surrogate variable to determine CVP among critical patients.