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Echocardiography in cardiac emergency
- 1. Dr. Ayman Abdelaziz Assisstant Prof. of Cardiology Mansoura University ECHOCARDIOGRAPHY IN EMERGENCY
- 2. CLINICAL INDICATION • 1- Hemodynamic instability and/or hypoxemia of unclear aetiolog (i) Suspected tamponade (ii) Pulseless electrical activity (PEA) can be the presenting symptom for: • Tamponade • Massive pulmonary embolism • Acute massive internal hemorrhage • Tension pneumothorax • 2- Aortic dissection 3- Acute coronary syndromes • 4- Acute valvular pathology, Prosthetic valve malfunction • 5- Infective endocarditis 6- Massive Pulmonary embolism • 7- Acute embolic event • 8- Critically ill patients due to non-cardiac illness: cardiac function and left ventricular (LV) filling may be crucial to guide fluid resuscitation: • (a) septic shock and (b) diabetic ketoacidosis.
- 3. ECHO ALGORITHM Unstable patient with shock or pulmonary oedema Quick targeted Echo (minimum views subcostal , Apical) moderate pericardial effusion Compressed RA/RV Collapsed IVC Severely enlarged akinetic RV Severe hypokinetic LV Small hyperdynamic heart Collapsed IVC Assume tamponade Assume pulmonary embolism Assume acute pump failure MI Myocarditis) Assume severe hypovolemia Major internal bleeding Sepsis
- 6. EUROECHO CONGRESS - COPENHAGEN - TEACHING COURSE 2010 RV and RA collapse • Without these collapses cardiac tamponade is unlikely
- 7. DIAGNOSIS • Echocardiogram (tamponade is clinical diagnosis) • Pericardial effusion • Early diastolic collapse of the right ventricular free wall • Late diastolic compression/collapse of the right atrium • Swinging of the heart in its sac • Respiratory variation of mitral and tricuspid flow • Dilated IVC (collapse < 50%)
- 13. RESPIRATORY VARIATION OF THE MITRAL FLOW
- 14. ECHO GUIDED- PERICARDIOCENTESIS • Subcostal approach • Traditional approach • Blind • Increased risk of injury to liver, heart • Echo guided • Left parasternal preferred for needle entry or… • Largest area of fluid collection adjacent to the chest wall
- 16. ECHOCARDIOGRAPHY IN PE: TO IDENTIFY RV OVERLOAD • RV dilatation. • Abnormal right ventricular wall motion. (McConnells sign) • Systolic flattening of the interventricular septum. • Tricuspid valve insufficiency • Increased pulmonary arterial pressure • Inferior vena cava congestion • Dilated pulmonary artery • Right-sided cardiac thrombus.
- 20. HYPOTENSION
- 21. ABNORMAL FINDINGS • Is the cause of hypotension cardiac in etiology? • Is it due to a pericardial effusion? • Is is due to pump failure?
- 22. UNEXPLAINED HYPOTENSION • Cardiogenic shock • Poor LV contractility • Hypovolemia • Hyperdynamic ventricules • Right ventricular infarct/large pulmonary embolism • Marked RV dilitation/hypokinesis • Tamponade • RV diastolic collapse
- 23. CARDIOGENIC SHOCK • Dilated left ventricle • Hypocontractile walls
- 24. • Small hyperdynamic heart • E/A < 1 • Small (< 20mm) IVC with exaggerated collapse with deep inspiration HYPOVOLEMIA
- 26. DIRECT VISUALIZATION • Is there effective myocardial contractility? • Asystole • Hypokinesis • Normal • Is there a pericardial effusion?
- 27. 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
- 28. ECHO IN PEA • RV dilatation • Hypoxic?? – Likely PE • ECG – IMI with RV infarct? • Profound hypokinesis • Inotropic support • Asystole • Follow ACLS protocols • Early data suggesting poor prognosis
- 29. ECHO IN PEA • False positive cardiac motion • Transthoracic pacemaker • Positive pressure ventilation
- 31. PENETRATING CARDIAC TRAUMA • Physician’s ability to determine whether there is a hemodynamically significant effusion is poor • Beck’s Triad • Dependent on patient cardiovascular status • Findings are often late • Determinants of hemodynamic compromise • Size of the effusion • Rate of formation
- 32. Acute coronary syndrome Echo in the assessment of complications
- 33. COMPLICATION OF AMI • Haemodynamic states Globally reduced LV contractility Hypovolumea Right ventricular infarction Ischemic MR • Mechanical Complications - Papillary muscle rupture - Ventricular septal rupture - Free wall rupture and tamponade • Other - Left ventricular aneurysm - Mural thrombus
- 34. Levine, R. A. N Engl J Med 2004;351:1681-1684 Ischaemic mitral regurgitation EUROECHO CONGRESS COPENHAGEN TEACHING COURSE 2010
- 43. ECHO ALGORITHM
- 44. ROLE OF TEE • Advantages: Ideal Dx test for AAS • Safe • Fast • Bedside exam or in OR w/o transport • Identifies extent and etiology of injury and associated complications • Sensitive (94-100%) and specific (77-100%) • Disadvantages: • Invasive • Sedation • TEE “blindspot” -- trachea between esophagus and upper ascending aorta
- 45. TRUE VS. FALSE LUMEN
- 46. TRUE VS. FALSE LUMEN
- 47. 17 TEE. Additional information I- Entry tear location and size
- 56. PROSTHETIC VALVE THROMBOSIS Risk factors • Inadequate oral anticoagulant • Interruption of oral anticoagulation (non cardiac surgery, pregnancy) • Prosthetic type: Starr Edwards • AF • Low EF < 35% • LA > 5cm • Spontanous echo contrast • MVR, TVR
- 57. ECHO • 1. To assess hemodynamic severity TTE and Doppler echo • 2. To assess valve motion and clot burden TEE and/or fluoroscopy
- 58. ECHOCARDIOGRAPHIC SIGNS OF OBSTRUCTIVE PVT • Reduced valve mobility • Presence of thrombus • Abnormal transprosthetic flow • Central prosthetic regurgitation • Elevated transprosthetic gradients • Reduced prosthetic area
- 62. DEHISCENCE
- 65. Thank you