SlideShare a Scribd company logo
1 of 54
UTILITY OF ECHO
IN RESUS
Sinéad Taylor
Emergency Registrar
Sir Charles Gairdner Hospital
Outline
1. Refresher on basic echocardiography views
2. Use of echocardiography in arrest and peri-arrest situations
1. Where does it fit in the ALS/ACLS algorithm?
2. Re-evaluating PEA
3. Finding a cause
4. When do we terminate CPR?
BASIC ECHO VIEWS
Echo Views
1. Parasternal long axis (PLAX)
2. Parasternal short axis (PSAX)
3. Apical view
4. Subcostal view
1. Parasternal long axis view
(PLAX)
1. Parasternal long axis view
(PLAX)
2. Parasternal Short Axis View
(PSAX)
Mitral valve
Mid-ventricular level
Apex
2. Parasternal Short Axis View
(PSAX)
Aortic valve level
2. Parasternal Short Axis View
(PSAX)
Mitral valve level
2. Parasternal Short Axis View
(PSAX)
Papillary muscle level
3. Apical View
3.1 Apical 4 Chamber View
3.1 Apical 5 Chamber View
4. Subcostal View
Subcostal long axis Subcostal short axis
4.1 Subcostal 4 Chamber View
4.2 IVC
ECHO IN CARDIAC
ARREST
What can an echo exam in
cardiac arrest achieve?
1. Identify the cause of the arrest
1. Treatable vs. non-treatable
2. Can rapidly change management
2. Assess PEA – is the patient truly pulseless?
3. Early detection of myocardial activity and ROSC
Where does echo fit in the ACLS
algorithm?
• Challenges of echo during cardiac arrest:
• Little space
• Little time
• Need to minimise interruptions to chest compressions/ACLS algorithm
• How do we overcome these obstacles?
• Pre-plan with ultrasound machine settings
• FEEL protocol (Focused Echocardiographic Evaluation in Life Support)
10 secs
PULSELESS
ELECTRICAL
ACTIVITY
Pulse Check
• It’s one of the first things we’re taught when we learn basic CPR/first aid,
but how useful is it?
• Problems:
• Takes time (sometimes even longer than 5 seconds in healthy people)
• Accuracy can be as low as 78%
• Lower in arrest – 45% of healthcare providers can’t accurately detect a central pulse!
• No palpable pulse
• (Semi) Organised electrical activity on monitor
• Organised cardiac activity on echo Pseudo PEA
CAUSES OF
ARREST
Causes of cardiorespiratory arrest
4 H’s
• Hypoxia
• Hypovolaemia
• Hypo/hyperkalaemia/ metabolic
disorders
• Hypo/hyperthermia
4 T’s
• Tension pneumothorax
• Tamponade
• Toxins
• Thrombosis (pulmonary or
cardiac)
Hypovolaemia
Zafiropoulos A, Asrress K, Redwood S, Gillon S, Walker D. CRITICAL CARE ECHO ROUNDS: Echo in cardiac arrest. Echo Research and Practice. 2014;1(2):D15-D21.
Hypovolaemia – LV size and
function
Hypovolaemia
Hypovolaemia - IVC
Hypovolaemia - IVC
• To determine hypovolaemia, we look at 2 different IVC parameters:
• Size
• Collapsibility index
• This then gives us an idea of right atrial pressure/CVP.
• 𝐶𝐼 % =
(𝐼𝑉𝐶𝐷 max − 𝐼𝑉𝐶𝐷 min) 𝑥100
𝐼𝑉𝐶𝐷 𝑚𝑎𝑥
• Probable non-fluid responders:
• <50% collapsibility index
• >2cm IVC diameter
• Probable fluid responders (i.e., hypovolaemic)
• >50% collapsibility index
• <1cm IVC diameter
So they’re hypovolaemic… but
why?
Splenic rupture
Large pleural effusion in the context of trauma
Tamponade
• Remember… tamponade is a clinical diagnosis.
• BUT if your patient is in cardiorespiratory arrest and you see the
following features, think of tamponade:
• RA collapse
• RV collapse
• IVC dilation
• Swinging heart
• Best views for tamponade:
• Subcostal – good for cardiac arrest, and you can assess IVC
• PLAX – is the fluid pericardial or a pleural effusion?
• Apical 4CV – look for RA and RV collapse
Tamponade
• How much fluid matters?
• It’s more about how quickly the fluid builds up, rather than the absolute
volume.
• Correlate what you’re looking at on echo with the patient’s clinical and
haemodynamic status.
Tamponade – RA wall collapse
Tamponade – RV wall collapse
Tamponade – swinging heart
Thrombosis - PE
• Sensitivity of echo for detecting PEs of any severity – approx 60%.
• However if your patient is unstable, an absence of echo evidence for RV
overload/dysfunction can exclude a PE(*)
• PE causing arrest
• 2/3 pulmonary vascular bed obstructed
•  sudden increase in afterload  dilation of right ventricle
• On echo:
• PLAX: Increase in RV diameter >30mm
• A4CV: increase in area of RV as compared to LV to 90%
• PSAX: D-shaped septum, paradoxical movement
(*) Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galie` N, Pruszczyk P, Bengel F, Brady AJ,
Ferreira D, Janssens U et al. 2008 Guidelines on the diagnosis and management of acute
pulmonary embolism: the Task Force for the diagnosis and management of acute pulmonary
embolism of the European Society of Cardiology (ESC). European Heart Journal 29 2276–2315.
PE Echo features
1. Echo dense thrombus – in RA or RV, IVC or pulmonary artery
2. RV strain
• Dilated RV
• Poorly contracting RV
• Reduced TAPSE
• Hyperdynamic LV
• RV free wall hypokinesis
3. RV overload
• D-shaped ventricle
• Dilated non-collapsing IVC
RV dilation
PE Echo features
The icing on the cake
The icing on the cake
Thrombosis: Cardiac
• Assess for regional wall abnormalities
https://www.ultrasoundoftheweek.com/uotw-36-answer/
Global hypokinesis
Wall motion abnormalities, worse in septal + apical segments
Cath lab: 100% ostial LAD lesion
WHEN DO WE
STOP CPR?
References
1. Carbonatto G. Point of Care Ultrasound Module 6: Echo. Lecture presented at; 2018; Sydney University Medical School.
2. Beraud A, Burkett T. Introduction to transthoracic echocardiography [Internet]. Koninklijke Philips; 2015 [cited 15 August 2018].
Available from: http://viewer.zmags.com/publication/3c9e5062#/3c9e5062/1
3. ANZCOR Adult Cardiorespiratory Arrest Flowchart [Internet]. Australian Resuscitation Council. 2016 [cited 15 August 2018].
Available from: https://resus.org.au/guidelines/flowcharts-3/
4. Zafiropoulos A, Asrress K, Redwood S, Gillon S, Walker D. CRITICAL CARE ECHO ROUNDS: Echo in cardiac arrest. Echo Research
and Practice. 2014;1(2):D15-D21.
5. Neskovic A, Hagendorff A, Lancellotti P, Guarracino F, Varga A, Cosyns B et al. Emergency echocardiography: the European
Association of Cardiovascular Imaging recommendations. European Heart Journal - Cardiovascular Imaging. 2012;14(1):1-11.
6. Breitkreutz R, Walcher F, Seeger F. Focused echocardiographic evaluation in resuscitation management: Concept of an
advanced life support–conformed algorithm. Critical Care Medicine. 2007;35(Suppl):S150-S161.
7. 7. Bystrzycki A. Ultrasound Village: ED Basic Echo - where does it fit? [Internet]. 2017 [cited 15 August 2018]. Available from:
https://www.youtube.com/watch?v=125wM8DrbNI
8. 8. Carbonatto G. Sepsis – Critical Care Sonography [Internet]. Criticalcare-sonography.com. 2016 [cited 15 August 2018].
Available from: https://www.criticalcare-sonography.com/2016/09/15/sepsis/
9. UOTW #36 Answer - Ultrasound of the Week [Internet]. Ultrasound of the Week. 2015 [cited 15 August 2018]. Available from:
https://www.ultrasoundoftheweek.com/uotw-36-answer/
10. 10. Thavanathan R, Hoang R. Look Deep Inside Yourself: Echo in Cardiac Arrest - EMOttawa [Internet]. EMOttawa. 2017 [cited 15
August 2018]. Available from: https://emottawablog.com/2017/09/look-deep-inside-yourself-echo-in-cardiac-arrest/
11. Tibballs, J., & Russell, P. (2017). Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest.
Resuscitation, 80(1), 61–64
12. Ochoa, F. J., Ramalle-Gómara, E., Carpintero, J. ., Garcı́a, A., & Saralegui, I. (1998). Competence of health professionals to check
the carotid pulse. Resuscitation, 37(3), 173–175
13. 11. Long B, Alerhand S, Maliel K, Koyfman A. Echocardiography in cardiac arrest: An emergency medicine review. American
Journal of Emergency Medicine. 2018;36:488-493.
14. 12. Blyth L, Atkinson P, Gadd K, Lang E. Bedside Focused Echocardiography as Predictor of Survival in Cardiac Arrest Patients: A
Systematic Review. Academic Emergency Medicine. 2012;19(10):1119-1126.

More Related Content

What's hot

Vso2(venous oximetry) mixed venous o2 sat
Vso2(venous oximetry) mixed venous o2 satVso2(venous oximetry) mixed venous o2 sat
Vso2(venous oximetry) mixed venous o2 satHossam atef
 
Static and dynamic indices of hemodynamic monitoring
Static and dynamic indices of hemodynamic monitoringStatic and dynamic indices of hemodynamic monitoring
Static and dynamic indices of hemodynamic monitoringBhargav Mundlapudi
 
Non-invasive haemodynamic monitoring by Echocardiography
Non-invasive haemodynamic monitoring by EchocardiographyNon-invasive haemodynamic monitoring by Echocardiography
Non-invasive haemodynamic monitoring by EchocardiographyHatem Soliman Aboumarie
 
Hemodynamic Pressure Monitoring
Hemodynamic Pressure MonitoringHemodynamic Pressure Monitoring
Hemodynamic Pressure MonitoringKhalid
 
Transesophageal echocardiography
Transesophageal echocardiographyTransesophageal echocardiography
Transesophageal echocardiographyAmit Gulati
 
INTRA-ARTERIAL BLOOD PRESSURE MONITORING
INTRA-ARTERIAL BLOOD PRESSURE MONITORING INTRA-ARTERIAL BLOOD PRESSURE MONITORING
INTRA-ARTERIAL BLOOD PRESSURE MONITORING vikramnaidu2311
 
Invasive blood pressure_monitoring
Invasive blood pressure_monitoringInvasive blood pressure_monitoring
Invasive blood pressure_monitoringUbaidur Rahaman
 
Cardiac output & monitoring
Cardiac output &  monitoringCardiac output &  monitoring
Cardiac output & monitoringArundev P Nair
 
Role of ultrasound in ICU
Role of ultrasound in ICURole of ultrasound in ICU
Role of ultrasound in ICUcairo1957
 
Assessment of shunt by cardiac catheterization
Assessment of shunt by cardiac catheterizationAssessment of shunt by cardiac catheterization
Assessment of shunt by cardiac catheterizationRamachandra Barik
 
Newer modes of ventilation
Newer modes of ventilationNewer modes of ventilation
Newer modes of ventilationRicha Kumar
 
Pulmonary artery catheter
Pulmonary artery catheterPulmonary artery catheter
Pulmonary artery catheterrajkumarsrihari
 
Basic transesophageal echo TEE anaesthesia
Basic transesophageal echo TEE anaesthesia Basic transesophageal echo TEE anaesthesia
Basic transesophageal echo TEE anaesthesia Prith Raj
 
Hemodynamic monitoring- Dr Sandeep Gampa
Hemodynamic monitoring- Dr Sandeep GampaHemodynamic monitoring- Dr Sandeep Gampa
Hemodynamic monitoring- Dr Sandeep GampaSiddharth Pandey
 
POCUS in critical care Jan 8th 2020 Teh Iran
POCUS in critical care Jan 8th 2020 Teh IranPOCUS in critical care Jan 8th 2020 Teh Iran
POCUS in critical care Jan 8th 2020 Teh Iranmansoor masjedi
 
Echo made easy
Echo made easyEcho made easy
Echo made easyHospital
 

What's hot (20)

Vso2(venous oximetry) mixed venous o2 sat
Vso2(venous oximetry) mixed venous o2 satVso2(venous oximetry) mixed venous o2 sat
Vso2(venous oximetry) mixed venous o2 sat
 
Static and dynamic indices of hemodynamic monitoring
Static and dynamic indices of hemodynamic monitoringStatic and dynamic indices of hemodynamic monitoring
Static and dynamic indices of hemodynamic monitoring
 
Non-invasive haemodynamic monitoring by Echocardiography
Non-invasive haemodynamic monitoring by EchocardiographyNon-invasive haemodynamic monitoring by Echocardiography
Non-invasive haemodynamic monitoring by Echocardiography
 
TRANS ESOPHAGEAL ECHOCARDIOGRAPHY
TRANS ESOPHAGEAL ECHOCARDIOGRAPHYTRANS ESOPHAGEAL ECHOCARDIOGRAPHY
TRANS ESOPHAGEAL ECHOCARDIOGRAPHY
 
Hemodynamic Pressure Monitoring
Hemodynamic Pressure MonitoringHemodynamic Pressure Monitoring
Hemodynamic Pressure Monitoring
 
Transesophageal echocardiography
Transesophageal echocardiographyTransesophageal echocardiography
Transesophageal echocardiography
 
INTRA-ARTERIAL BLOOD PRESSURE MONITORING
INTRA-ARTERIAL BLOOD PRESSURE MONITORING INTRA-ARTERIAL BLOOD PRESSURE MONITORING
INTRA-ARTERIAL BLOOD PRESSURE MONITORING
 
Invasive blood pressure_monitoring
Invasive blood pressure_monitoringInvasive blood pressure_monitoring
Invasive blood pressure_monitoring
 
Cardiac output & monitoring
Cardiac output &  monitoringCardiac output &  monitoring
Cardiac output & monitoring
 
Role of ultrasound in ICU
Role of ultrasound in ICURole of ultrasound in ICU
Role of ultrasound in ICU
 
Pulmonary artery Catheter
Pulmonary artery CatheterPulmonary artery Catheter
Pulmonary artery Catheter
 
Assessment of shunt by cardiac catheterization
Assessment of shunt by cardiac catheterizationAssessment of shunt by cardiac catheterization
Assessment of shunt by cardiac catheterization
 
Newer modes of ventilation
Newer modes of ventilationNewer modes of ventilation
Newer modes of ventilation
 
Ventilator Graphics
Ventilator GraphicsVentilator Graphics
Ventilator Graphics
 
Pulmonary artery catheter
Pulmonary artery catheterPulmonary artery catheter
Pulmonary artery catheter
 
Basic transesophageal echo TEE anaesthesia
Basic transesophageal echo TEE anaesthesia Basic transesophageal echo TEE anaesthesia
Basic transesophageal echo TEE anaesthesia
 
Hemodynamic monitoring- Dr Sandeep Gampa
Hemodynamic monitoring- Dr Sandeep GampaHemodynamic monitoring- Dr Sandeep Gampa
Hemodynamic monitoring- Dr Sandeep Gampa
 
POCUS in critical care Jan 8th 2020 Teh Iran
POCUS in critical care Jan 8th 2020 Teh IranPOCUS in critical care Jan 8th 2020 Teh Iran
POCUS in critical care Jan 8th 2020 Teh Iran
 
Basics of echocardiograghy
Basics of echocardiograghyBasics of echocardiograghy
Basics of echocardiograghy
 
Echo made easy
Echo made easyEcho made easy
Echo made easy
 

Similar to Ultrasound in cardiac arrest

CARDIAC INDICES(1)-1.pptx
CARDIAC INDICES(1)-1.pptxCARDIAC INDICES(1)-1.pptx
CARDIAC INDICES(1)-1.pptxKemi Adaramola
 
Pulmonary hypertension dr md toufiqur rahman dm fcps frcp fesc faha fscai fapsic
Pulmonary hypertension dr md toufiqur rahman dm fcps frcp fesc faha fscai fapsicPulmonary hypertension dr md toufiqur rahman dm fcps frcp fesc faha fscai fapsic
Pulmonary hypertension dr md toufiqur rahman dm fcps frcp fesc faha fscai fapsicPROFESSOR DR. MD. TOUFIQUR RAHMAN
 
Ecocardio fallo cardiaco.pdf
Ecocardio fallo cardiaco.pdfEcocardio fallo cardiaco.pdf
Ecocardio fallo cardiaco.pdfleroleroero1
 
Bedside monitoring of tissue perfusion and oxygenation
Bedside monitoring of tissue perfusion and oxygenationBedside monitoring of tissue perfusion and oxygenation
Bedside monitoring of tissue perfusion and oxygenationDr. Tushar Patil
 
APPROACH TO PULMONARY HYPERTENSION.pptx
APPROACH TO PULMONARY HYPERTENSION.pptxAPPROACH TO PULMONARY HYPERTENSION.pptx
APPROACH TO PULMONARY HYPERTENSION.pptxDr Soumitra Mondal
 
Evaluation and Management of pulmonary artery hypertension - dr sandeep mohan...
Evaluation and Management of pulmonary artery hypertension - dr sandeep mohan...Evaluation and Management of pulmonary artery hypertension - dr sandeep mohan...
Evaluation and Management of pulmonary artery hypertension - dr sandeep mohan...YolaNewary1
 
Point of Care Lung Ultrasound
Point of Care Lung UltrasoundPoint of Care Lung Ultrasound
Point of Care Lung UltrasoundAnoop James
 
Ultrasound updates for Sydney HEMS
Ultrasound updates for Sydney HEMSUltrasound updates for Sydney HEMS
Ultrasound updates for Sydney HEMSchrispartyka
 
Focused Cardiac Ultrasound
Focused Cardiac UltrasoundFocused Cardiac Ultrasound
Focused Cardiac UltrasoundSun Yai-Cheng
 
2D ECHO in pulmonology
2D ECHO in pulmonology2D ECHO in pulmonology
2D ECHO in pulmonologyvenu3434
 
2016 recommendations for the evaluation of left ventricular diastolic functio...
2016 recommendations for the evaluation of left ventricular diastolic functio...2016 recommendations for the evaluation of left ventricular diastolic functio...
2016 recommendations for the evaluation of left ventricular diastolic functio...Alexandria University, Egypt
 
How accurate electrocardiogram predict LV diastolic dysfunction?
How accurate electrocardiogram predict LV diastolic dysfunction?How accurate electrocardiogram predict LV diastolic dysfunction?
How accurate electrocardiogram predict LV diastolic dysfunction?Tamer Taha
 
Vascular Laboratory: Arterial Physiologic Assessment & Arterial Duplex Scanning
Vascular Laboratory: Arterial Physiologic Assessment & Arterial Duplex ScanningVascular Laboratory: Arterial Physiologic Assessment & Arterial Duplex Scanning
Vascular Laboratory: Arterial Physiologic Assessment & Arterial Duplex ScanningTapish Sahu
 
Rush Exam
Rush ExamRush Exam
Rush ExamEM OMSB
 
Shunt quantification and reversibility
Shunt quantification and reversibilityShunt quantification and reversibility
Shunt quantification and reversibilityGOPAL GHOSH
 
Introduction to ecg
Introduction to ecgIntroduction to ecg
Introduction to ecgS P
 

Similar to Ultrasound in cardiac arrest (20)

CARDIAC INDICES(1)-1.pptx
CARDIAC INDICES(1)-1.pptxCARDIAC INDICES(1)-1.pptx
CARDIAC INDICES(1)-1.pptx
 
Pulmonary hypertension dr md toufiqur rahman dm fcps frcp fesc faha fscai fapsic
Pulmonary hypertension dr md toufiqur rahman dm fcps frcp fesc faha fscai fapsicPulmonary hypertension dr md toufiqur rahman dm fcps frcp fesc faha fscai fapsic
Pulmonary hypertension dr md toufiqur rahman dm fcps frcp fesc faha fscai fapsic
 
Ecocardio fallo cardiaco.pdf
Ecocardio fallo cardiaco.pdfEcocardio fallo cardiaco.pdf
Ecocardio fallo cardiaco.pdf
 
Bedside monitoring of tissue perfusion and oxygenation
Bedside monitoring of tissue perfusion and oxygenationBedside monitoring of tissue perfusion and oxygenation
Bedside monitoring of tissue perfusion and oxygenation
 
APPROACH TO PULMONARY HYPERTENSION.pptx
APPROACH TO PULMONARY HYPERTENSION.pptxAPPROACH TO PULMONARY HYPERTENSION.pptx
APPROACH TO PULMONARY HYPERTENSION.pptx
 
Evaluation and Management of pulmonary artery hypertension - dr sandeep mohan...
Evaluation and Management of pulmonary artery hypertension - dr sandeep mohan...Evaluation and Management of pulmonary artery hypertension - dr sandeep mohan...
Evaluation and Management of pulmonary artery hypertension - dr sandeep mohan...
 
Point of Care Lung Ultrasound
Point of Care Lung UltrasoundPoint of Care Lung Ultrasound
Point of Care Lung Ultrasound
 
Monitoring in ICU
Monitoring in ICUMonitoring in ICU
Monitoring in ICU
 
Ultrasound updates for Sydney HEMS
Ultrasound updates for Sydney HEMSUltrasound updates for Sydney HEMS
Ultrasound updates for Sydney HEMS
 
Focused Cardiac Ultrasound
Focused Cardiac UltrasoundFocused Cardiac Ultrasound
Focused Cardiac Ultrasound
 
Shock
ShockShock
Shock
 
2D ECHO in pulmonology
2D ECHO in pulmonology2D ECHO in pulmonology
2D ECHO in pulmonology
 
TRANSESOPHAGEAL ECHOCARDIOGRAPHY.pptx
TRANSESOPHAGEAL ECHOCARDIOGRAPHY.pptxTRANSESOPHAGEAL ECHOCARDIOGRAPHY.pptx
TRANSESOPHAGEAL ECHOCARDIOGRAPHY.pptx
 
2016 recommendations for the evaluation of left ventricular diastolic functio...
2016 recommendations for the evaluation of left ventricular diastolic functio...2016 recommendations for the evaluation of left ventricular diastolic functio...
2016 recommendations for the evaluation of left ventricular diastolic functio...
 
How accurate electrocardiogram predict LV diastolic dysfunction?
How accurate electrocardiogram predict LV diastolic dysfunction?How accurate electrocardiogram predict LV diastolic dysfunction?
How accurate electrocardiogram predict LV diastolic dysfunction?
 
Vascular Laboratory: Arterial Physiologic Assessment & Arterial Duplex Scanning
Vascular Laboratory: Arterial Physiologic Assessment & Arterial Duplex ScanningVascular Laboratory: Arterial Physiologic Assessment & Arterial Duplex Scanning
Vascular Laboratory: Arterial Physiologic Assessment & Arterial Duplex Scanning
 
Rush Exam
Rush ExamRush Exam
Rush Exam
 
Shunt quantification and reversibility
Shunt quantification and reversibilityShunt quantification and reversibility
Shunt quantification and reversibility
 
Introduction to ecg
Introduction to ecgIntroduction to ecg
Introduction to ecg
 
Ecg
EcgEcg
Ecg
 

More from SCGH ED CME

Haemostatic resuscitation
Haemostatic resuscitationHaemostatic resuscitation
Haemostatic resuscitationSCGH ED CME
 
Goals of patient care introduction
Goals of patient care introductionGoals of patient care introduction
Goals of patient care introductionSCGH ED CME
 
Physiology Directed CPR
Physiology Directed CPRPhysiology Directed CPR
Physiology Directed CPRSCGH ED CME
 
Ultrasound confirmation of ETT placement
Ultrasound confirmation of ETT placementUltrasound confirmation of ETT placement
Ultrasound confirmation of ETT placementSCGH ED CME
 
Palliative care in the emergency department
Palliative care in the emergency departmentPalliative care in the emergency department
Palliative care in the emergency departmentSCGH ED CME
 
Wilderness crisis and decision making weekend April 2018
Wilderness crisis and decision making weekend April 2018Wilderness crisis and decision making weekend April 2018
Wilderness crisis and decision making weekend April 2018SCGH ED CME
 
Patient confidentiality in emergency department
Patient confidentiality in emergency departmentPatient confidentiality in emergency department
Patient confidentiality in emergency departmentSCGH ED CME
 
Abscess management
Abscess managementAbscess management
Abscess managementSCGH ED CME
 
Hyperthermia and hypothermia
Hyperthermia and hypothermiaHyperthermia and hypothermia
Hyperthermia and hypothermiaSCGH ED CME
 
It's all about the documentation
It's all about the documentationIt's all about the documentation
It's all about the documentationSCGH ED CME
 
Choosing Wisely - Rational Antibiotic Usage
Choosing Wisely - Rational Antibiotic UsageChoosing Wisely - Rational Antibiotic Usage
Choosing Wisely - Rational Antibiotic UsageSCGH ED CME
 
What's Hot in Emergency Medicine June 2018
What's Hot in Emergency Medicine June 2018What's Hot in Emergency Medicine June 2018
What's Hot in Emergency Medicine June 2018SCGH ED CME
 
Emergency ophthalmology
Emergency ophthalmologyEmergency ophthalmology
Emergency ophthalmologySCGH ED CME
 
Code Brown - Disaster Medicine in the ED
Code Brown - Disaster Medicine in the EDCode Brown - Disaster Medicine in the ED
Code Brown - Disaster Medicine in the EDSCGH ED CME
 

More from SCGH ED CME (20)

Trauma teams
Trauma teamsTrauma teams
Trauma teams
 
Haemostatic resuscitation
Haemostatic resuscitationHaemostatic resuscitation
Haemostatic resuscitation
 
Arthrocentesis
ArthrocentesisArthrocentesis
Arthrocentesis
 
Goals of patient care introduction
Goals of patient care introductionGoals of patient care introduction
Goals of patient care introduction
 
Physiology Directed CPR
Physiology Directed CPRPhysiology Directed CPR
Physiology Directed CPR
 
Ultrasound confirmation of ETT placement
Ultrasound confirmation of ETT placementUltrasound confirmation of ETT placement
Ultrasound confirmation of ETT placement
 
Palliative care in the emergency department
Palliative care in the emergency departmentPalliative care in the emergency department
Palliative care in the emergency department
 
Wilderness crisis and decision making weekend April 2018
Wilderness crisis and decision making weekend April 2018Wilderness crisis and decision making weekend April 2018
Wilderness crisis and decision making weekend April 2018
 
Patient confidentiality in emergency department
Patient confidentiality in emergency departmentPatient confidentiality in emergency department
Patient confidentiality in emergency department
 
Abscess management
Abscess managementAbscess management
Abscess management
 
Hyperthermia and hypothermia
Hyperthermia and hypothermiaHyperthermia and hypothermia
Hyperthermia and hypothermia
 
Electrical injury
Electrical injuryElectrical injury
Electrical injury
 
D-dimer audit
D-dimer auditD-dimer audit
D-dimer audit
 
It's all about the documentation
It's all about the documentationIt's all about the documentation
It's all about the documentation
 
Paediatric rashes
Paediatric rashesPaediatric rashes
Paediatric rashes
 
Choosing Wisely - Rational Antibiotic Usage
Choosing Wisely - Rational Antibiotic UsageChoosing Wisely - Rational Antibiotic Usage
Choosing Wisely - Rational Antibiotic Usage
 
What's Hot in Emergency Medicine June 2018
What's Hot in Emergency Medicine June 2018What's Hot in Emergency Medicine June 2018
What's Hot in Emergency Medicine June 2018
 
Emergency ophthalmology
Emergency ophthalmologyEmergency ophthalmology
Emergency ophthalmology
 
Code Brown - Disaster Medicine in the ED
Code Brown - Disaster Medicine in the EDCode Brown - Disaster Medicine in the ED
Code Brown - Disaster Medicine in the ED
 
Physician burnout
Physician burnoutPhysician burnout
Physician burnout
 

Recently uploaded

Lucknow Call girls - 8800925952 - 24x7 service with hotel room
Lucknow Call girls - 8800925952 - 24x7 service with hotel roomLucknow Call girls - 8800925952 - 24x7 service with hotel room
Lucknow Call girls - 8800925952 - 24x7 service with hotel roomdiscovermytutordmt
 
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...perfect solution
 
Top Rated Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...
Top Rated  Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...Top Rated  Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...
Top Rated Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...chandars293
 
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any TimeTop Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any TimeCall Girls Delhi
 
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort ServicePremium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Servicevidya singh
 
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Kochi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Chandrapur Call girls 8617370543 Provides all area service COD available
Chandrapur Call girls 8617370543 Provides all area service COD availableChandrapur Call girls 8617370543 Provides all area service COD available
Chandrapur Call girls 8617370543 Provides all area service COD availableDipal Arora
 
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...Garima Khatri
 
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Bangalore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...Taniya Sharma
 
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...Arohi Goyal
 
Call Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...hotbabesbook
 
Russian Call Girls in Jaipur Riya WhatsApp ❤8445551418 VIP Call Girls Jaipur
Russian Call Girls in Jaipur Riya WhatsApp ❤8445551418 VIP Call Girls JaipurRussian Call Girls in Jaipur Riya WhatsApp ❤8445551418 VIP Call Girls Jaipur
Russian Call Girls in Jaipur Riya WhatsApp ❤8445551418 VIP Call Girls Jaipurparulsinha
 
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...aartirawatdelhi
 
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...Dipal Arora
 
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Varanasi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Top Rated Bangalore Call Girls Mg Road ⟟ 8250192130 ⟟ Call Me For Genuine Sex...
Top Rated Bangalore Call Girls Mg Road ⟟ 8250192130 ⟟ Call Me For Genuine Sex...Top Rated Bangalore Call Girls Mg Road ⟟ 8250192130 ⟟ Call Me For Genuine Sex...
Top Rated Bangalore Call Girls Mg Road ⟟ 8250192130 ⟟ Call Me For Genuine Sex...narwatsonia7
 
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 

Recently uploaded (20)

Lucknow Call girls - 8800925952 - 24x7 service with hotel room
Lucknow Call girls - 8800925952 - 24x7 service with hotel roomLucknow Call girls - 8800925952 - 24x7 service with hotel room
Lucknow Call girls - 8800925952 - 24x7 service with hotel room
 
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...
 
Top Rated Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...
Top Rated  Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...Top Rated  Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...
Top Rated Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...
 
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any TimeTop Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
 
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort ServicePremium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service
 
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Kochi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service Available
 
Chandrapur Call girls 8617370543 Provides all area service COD available
Chandrapur Call girls 8617370543 Provides all area service COD availableChandrapur Call girls 8617370543 Provides all area service COD available
Chandrapur Call girls 8617370543 Provides all area service COD available
 
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
 
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Bangalore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service Available
 
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...
 
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
 
Call Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service Available
 
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
 
Russian Call Girls in Jaipur Riya WhatsApp ❤8445551418 VIP Call Girls Jaipur
Russian Call Girls in Jaipur Riya WhatsApp ❤8445551418 VIP Call Girls JaipurRussian Call Girls in Jaipur Riya WhatsApp ❤8445551418 VIP Call Girls Jaipur
Russian Call Girls in Jaipur Riya WhatsApp ❤8445551418 VIP Call Girls Jaipur
 
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
 
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
 
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...
 
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Varanasi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service Available
 
Top Rated Bangalore Call Girls Mg Road ⟟ 8250192130 ⟟ Call Me For Genuine Sex...
Top Rated Bangalore Call Girls Mg Road ⟟ 8250192130 ⟟ Call Me For Genuine Sex...Top Rated Bangalore Call Girls Mg Road ⟟ 8250192130 ⟟ Call Me For Genuine Sex...
Top Rated Bangalore Call Girls Mg Road ⟟ 8250192130 ⟟ Call Me For Genuine Sex...
 
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service Available
 

Ultrasound in cardiac arrest

  • 1. UTILITY OF ECHO IN RESUS Sinéad Taylor Emergency Registrar Sir Charles Gairdner Hospital
  • 2. Outline 1. Refresher on basic echocardiography views 2. Use of echocardiography in arrest and peri-arrest situations 1. Where does it fit in the ALS/ACLS algorithm? 2. Re-evaluating PEA 3. Finding a cause 4. When do we terminate CPR?
  • 4. Echo Views 1. Parasternal long axis (PLAX) 2. Parasternal short axis (PSAX) 3. Apical view 4. Subcostal view
  • 5. 1. Parasternal long axis view (PLAX)
  • 6. 1. Parasternal long axis view (PLAX)
  • 7. 2. Parasternal Short Axis View (PSAX) Mitral valve Mid-ventricular level Apex
  • 8. 2. Parasternal Short Axis View (PSAX) Aortic valve level
  • 9. 2. Parasternal Short Axis View (PSAX) Mitral valve level
  • 10. 2. Parasternal Short Axis View (PSAX) Papillary muscle level
  • 12. 3.1 Apical 4 Chamber View
  • 13. 3.1 Apical 5 Chamber View
  • 14. 4. Subcostal View Subcostal long axis Subcostal short axis
  • 15. 4.1 Subcostal 4 Chamber View
  • 18.
  • 19. What can an echo exam in cardiac arrest achieve? 1. Identify the cause of the arrest 1. Treatable vs. non-treatable 2. Can rapidly change management 2. Assess PEA – is the patient truly pulseless? 3. Early detection of myocardial activity and ROSC
  • 20. Where does echo fit in the ACLS algorithm? • Challenges of echo during cardiac arrest: • Little space • Little time • Need to minimise interruptions to chest compressions/ACLS algorithm • How do we overcome these obstacles? • Pre-plan with ultrasound machine settings • FEEL protocol (Focused Echocardiographic Evaluation in Life Support)
  • 23. Pulse Check • It’s one of the first things we’re taught when we learn basic CPR/first aid, but how useful is it? • Problems: • Takes time (sometimes even longer than 5 seconds in healthy people) • Accuracy can be as low as 78% • Lower in arrest – 45% of healthcare providers can’t accurately detect a central pulse! • No palpable pulse • (Semi) Organised electrical activity on monitor • Organised cardiac activity on echo Pseudo PEA
  • 25. Causes of cardiorespiratory arrest 4 H’s • Hypoxia • Hypovolaemia • Hypo/hyperkalaemia/ metabolic disorders • Hypo/hyperthermia 4 T’s • Tension pneumothorax • Tamponade • Toxins • Thrombosis (pulmonary or cardiac)
  • 26. Hypovolaemia Zafiropoulos A, Asrress K, Redwood S, Gillon S, Walker D. CRITICAL CARE ECHO ROUNDS: Echo in cardiac arrest. Echo Research and Practice. 2014;1(2):D15-D21.
  • 27. Hypovolaemia – LV size and function
  • 30. Hypovolaemia - IVC • To determine hypovolaemia, we look at 2 different IVC parameters: • Size • Collapsibility index • This then gives us an idea of right atrial pressure/CVP. • 𝐶𝐼 % = (𝐼𝑉𝐶𝐷 max − 𝐼𝑉𝐶𝐷 min) 𝑥100 𝐼𝑉𝐶𝐷 𝑚𝑎𝑥 • Probable non-fluid responders: • <50% collapsibility index • >2cm IVC diameter • Probable fluid responders (i.e., hypovolaemic) • >50% collapsibility index • <1cm IVC diameter
  • 32.
  • 34. Large pleural effusion in the context of trauma
  • 35.
  • 36.
  • 37. Tamponade • Remember… tamponade is a clinical diagnosis. • BUT if your patient is in cardiorespiratory arrest and you see the following features, think of tamponade: • RA collapse • RV collapse • IVC dilation • Swinging heart • Best views for tamponade: • Subcostal – good for cardiac arrest, and you can assess IVC • PLAX – is the fluid pericardial or a pleural effusion? • Apical 4CV – look for RA and RV collapse
  • 38. Tamponade • How much fluid matters? • It’s more about how quickly the fluid builds up, rather than the absolute volume. • Correlate what you’re looking at on echo with the patient’s clinical and haemodynamic status.
  • 39. Tamponade – RA wall collapse
  • 40. Tamponade – RV wall collapse
  • 42. Thrombosis - PE • Sensitivity of echo for detecting PEs of any severity – approx 60%. • However if your patient is unstable, an absence of echo evidence for RV overload/dysfunction can exclude a PE(*) • PE causing arrest • 2/3 pulmonary vascular bed obstructed •  sudden increase in afterload  dilation of right ventricle • On echo: • PLAX: Increase in RV diameter >30mm • A4CV: increase in area of RV as compared to LV to 90% • PSAX: D-shaped septum, paradoxical movement (*) Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galie` N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U et al. 2008 Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). European Heart Journal 29 2276–2315.
  • 43. PE Echo features 1. Echo dense thrombus – in RA or RV, IVC or pulmonary artery 2. RV strain • Dilated RV • Poorly contracting RV • Reduced TAPSE • Hyperdynamic LV • RV free wall hypokinesis 3. RV overload • D-shaped ventricle • Dilated non-collapsing IVC
  • 46. The icing on the cake
  • 47. The icing on the cake
  • 48. Thrombosis: Cardiac • Assess for regional wall abnormalities
  • 50. Cath lab: 100% ostial LAD lesion
  • 52.
  • 53.
  • 54. References 1. Carbonatto G. Point of Care Ultrasound Module 6: Echo. Lecture presented at; 2018; Sydney University Medical School. 2. Beraud A, Burkett T. Introduction to transthoracic echocardiography [Internet]. Koninklijke Philips; 2015 [cited 15 August 2018]. Available from: http://viewer.zmags.com/publication/3c9e5062#/3c9e5062/1 3. ANZCOR Adult Cardiorespiratory Arrest Flowchart [Internet]. Australian Resuscitation Council. 2016 [cited 15 August 2018]. Available from: https://resus.org.au/guidelines/flowcharts-3/ 4. Zafiropoulos A, Asrress K, Redwood S, Gillon S, Walker D. CRITICAL CARE ECHO ROUNDS: Echo in cardiac arrest. Echo Research and Practice. 2014;1(2):D15-D21. 5. Neskovic A, Hagendorff A, Lancellotti P, Guarracino F, Varga A, Cosyns B et al. Emergency echocardiography: the European Association of Cardiovascular Imaging recommendations. European Heart Journal - Cardiovascular Imaging. 2012;14(1):1-11. 6. Breitkreutz R, Walcher F, Seeger F. Focused echocardiographic evaluation in resuscitation management: Concept of an advanced life support–conformed algorithm. Critical Care Medicine. 2007;35(Suppl):S150-S161. 7. 7. Bystrzycki A. Ultrasound Village: ED Basic Echo - where does it fit? [Internet]. 2017 [cited 15 August 2018]. Available from: https://www.youtube.com/watch?v=125wM8DrbNI 8. 8. Carbonatto G. Sepsis – Critical Care Sonography [Internet]. Criticalcare-sonography.com. 2016 [cited 15 August 2018]. Available from: https://www.criticalcare-sonography.com/2016/09/15/sepsis/ 9. UOTW #36 Answer - Ultrasound of the Week [Internet]. Ultrasound of the Week. 2015 [cited 15 August 2018]. Available from: https://www.ultrasoundoftheweek.com/uotw-36-answer/ 10. 10. Thavanathan R, Hoang R. Look Deep Inside Yourself: Echo in Cardiac Arrest - EMOttawa [Internet]. EMOttawa. 2017 [cited 15 August 2018]. Available from: https://emottawablog.com/2017/09/look-deep-inside-yourself-echo-in-cardiac-arrest/ 11. Tibballs, J., & Russell, P. (2017). Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation, 80(1), 61–64 12. Ochoa, F. J., Ramalle-Gómara, E., Carpintero, J. ., Garcı́a, A., & Saralegui, I. (1998). Competence of health professionals to check the carotid pulse. Resuscitation, 37(3), 173–175 13. 11. Long B, Alerhand S, Maliel K, Koyfman A. Echocardiography in cardiac arrest: An emergency medicine review. American Journal of Emergency Medicine. 2018;36:488-493. 14. 12. Blyth L, Atkinson P, Gadd K, Lang E. Bedside Focused Echocardiography as Predictor of Survival in Cardiac Arrest Patients: A Systematic Review. Academic Emergency Medicine. 2012;19(10):1119-1126.

Editor's Notes

  1. I’m sure a lot of you already know what these are, but for those of you who are a bit rusty here’s a brief refresher. I’m not going to spend a lot of time on this as echo is a huge topic, and I’m by no means an expert by any stretch of the imagination.
  2. Start with the probe at 10 o’clock, towards the patient’s right shoulder. Ideally the patient will be in a steep left lateral decubitus. Start with the probe high up on the chest, then come down rib space by rib space until you see the view that you want
  3. It’s here in the parasternal long axis that you do most of your calculations. By using M-mode you can measure the left ventricle end diastolic diameter, left ventricular end systolic diameter, and the machine can then calculate the fractional shortening and ejection fraction from these. We can then use the ejection fraction to assess myocardial function. You can also look at the aortic root and ascending aorta. BUT this starts to get into some pretty advanced echo stuff, which is a bit beyond me. So here’s a very quick way to “eyeball” LV contraction and RV size.
  4. To get from long axis to parasternal short axis is really easy. When you’re in long axis get the mitral valve in the middle of the screen, then rotate 90 degrees to get to the short axis. You can then use really small movements of your wrist and fan up and down the heart, to look at all these different levels: Mitral valve Mid ventricular level (through the papillary muscles) Apex Aortic root level Pulmonary bifurcation
  5. Aortic valve level Right atrium Tricuspid valve Right ventricular outflow tract (RVOT) Pulmonary valve Pulmonary artery Aortic valve Left atrium
  6. There are lots of different apical views like 2 chamber, 3 chamber, but today we’re just going to focus on 4 chamber and 5 chamber views. You can achieve this by: Rolling the patient into a left posterior oblique position Placing the probe over the apical pulse (5th intercostal space, mid-axillary line) Index marker between 2 and 3 o’clock Tilt the probe anteriorly to transect all chambers
  7. To get to this from the apical 4 chamber view, just tilt the probe slightly anteriorly until you see the aortic valve. This view is useful for assessing aortic motion and regurg, but beware if you’re using this view to assess the chambers themselves as they’ll be foreshortened.
  8. You can use the subcostal window to look both a long and short axis view, and it can sometimes be the only window that you’ll get. This is a really important view to master for echo in a cardiac arrest, as if the lucas is on you won’t be able to place your probe in the spots needed for the other views. To achieve this view, you look at the heart using the liver as a sonographic window.
  9. You can also use the subcostal view to look at the IVC, and it’s here that you measure the IVC from inner wall to inner wall, making sure that you’re measuring 0.5-3cm from the right atrium. You can use the middle hepatic vein as a landmark and measure just distal to it, in inspiration and expiration.
  10. It can be a bit of a fight for space in a resus scenario, especially if the patient has arrested! You’ve got: People doing CPR (or the lucas on), nurses trying to cut the patient’s clothes off and attach monitoring A stressed intern trying to get access Another doctor trying to examine the patient And then someone comes in with the massive ultrasound machine, trying not to run over people’s toes, and throws a probe on as well. You only have a few seconds in between compressions to get your views. So given we’re so short on space AND time, the patient’s already arrested, and that we’re following a very clear ACLS guideline, how much can an echo really add?
  11. The FEEL protocol was developed to help physicians fit echo into a cardiac arrest algorithm.
  12. In an arrest scenario, the subcostal view might be the best, especially if the lucas is on. Alternatively, a very experienced practitioner might be able to het parasternal or apical view whilst compressions are ongoing.
  13. Here you’ve got a normal heart, and a hypovolaemic heart. In a normal heart, the left ventricular cavity narrows by half in each cardiac cycle. But as you can see in the second image, the ventricular walls are kissing – so posterior wall of LV and interventricular septum come together in systole, and the left ventricle at the end of systole is obliterated. There are some pitfalls to be noted – particularly inotropic support, severe valvular regurg, or left ventricular hypertrophy. The other thing to note that this method of assessment requires a beating heart, which limits its applicability in a cardiac arrest scenario. There are also static measurements such as LV end diastolic area or diameter and ejection fraction that can be taken, but they need a bit of time to measure, and if you don’t get the image just right then they can also be very prone to error. So if you’re like me and you’re not an expert in echo, it’s best to avoid this in an emergency situation.
  14. PSAX at level of papillary muscle with kissing walls and cavity obliteration due to hypovolaemia Apical 4 chamber view – small LV cavity
  15. Tamponade is a clinical diagnosis that you need to make based on BP, HR and respiratory status.
  16. TAPSE (tricuspid annular plane systolic excursion) – measures right ventricular function. Again, this is advanced and difficult to obtain during CPR, unless you’re doing transoesophageal echo. Again, a lot of these echo features are a bit more advanced.