Focused Echocardiographic Examination in the Emergency Room and Critical Care Units

1. Focused EchocardiographicExamination in the Emergency Room and Critical Care Units Ronald E. Cuyco, MD, FPCC

2. Emergency Echocardiography Advantages of echocardiography as a diagnostic tool in the emergency room and in the ICU: • Safe and tolerable • Easily reproducible • Readily available (portability) • Relatively low-cost • No radiation

3. Emergency Echocardiography What emergency situations should be assessed? • Acute chest pains • Acute dyspnea • Hemodynamic instability (hypotension/shock) • New murmur • Chest trauma • Cardiac sources of embolism • Cardiac arrest/CPR ESC Congress 2011

4. Emergency Echocardiography Where can emergency echocardiography be performed? • Emergency room • CCU –Coronary Care Unit • ICU/cardiac ICU – Intensive Care Unit • Operating room • Cardiac catheterization laboratory • Bedside • Ambulance (hand-held echocardiography) • Outside of the hospital ESC Congress 2011

5. Emergency Echocardiography Philippine Heart Center Echocardiograpy Census (2011) Total In-patient Echo 4,407 Bedside Echo (ER and ICU) 1,110 (25%) Intra-operative TEE (IOTEE) 221 ( 5%) Top 3 indications for emergency echocardiography: • Chest pains • Dyspnea • Hypotension

6. Emergency Echocardiography Acute chest pains and dyspnea • Acute myocardial ischemia or infarction • Aortic dissection • Pulmonary embolism

7. Emergency Echocardiography: Aortic Dissection TTE findings associated with aortic dissection • Aortic insufficiency • Enlarged aortic root (>3.5 cm at annulus or sino-tubular junction) • Presence of pericardial effusion • Infero-posterior wall motion abnormality (RCA territory)

8. Emergency Echocardiography Aortic Dissection • May require TEE to visualize distal ascending aorta, transverse and descending aorta • Intimal flap seen on TTE would clinch a diagnosis of aortic dissection • Lack of definite signs on TTE/TEE does not exclude an aortic dissection, CLINICAL DATA still important

9. Echo: Aortic dissection Suprasternal view of aorta showing the intimal flap Color flow doppler within the false and true lumen

10. Cardiac CT-MRI: Aortic Dissection • Complimentary tools to emergency echocardiography to rule-in or rule-out aortic dissection • Cardiovascular CT-MRI “triple rule-out” capability is an advantage over other modalities • Disadvantages: not readily available, non-portable, expensive, and requires highly skilled technician and staff

11. Emergency Echocardiography: Acute Coronary Syndrome • Wall thickening abnormalities • Evidence of ruptured interventricular septum, LV free wall or papillary muscle • LV systolic and diastolic functions • Cardiac filling pressures • Pulmonary pressure

12. Acute myocardial infarction with Ruptured Ventricular Septum 4-chamber view showing the echo drop-out space across the IV septum Color flow doppler demonstrating mosaic flow across the septal defect

13. LV systolic function • LV systolic function is not just EF! • Fractional shortening • Stroke volume • Cardiac index • Systolic tissue velocity of the mitral annulus and myocardium • Strain • Regional wall motion

14. Stroke volume

15. Simpson’s rule

16. M-Mode Recommendations for Chamber Quantification: A Report from the American Society of Echocardiography Guidelines and Standards Committee and the Chamber Quantification Writing Group, Developed in Conjunction with the European Association of Echocardiography, a Branch of the European Society of Cardiology

17. Systolic tissue Doppler velocity in normal and abnormal Normal Sm = 12 cm/sec Abnormal Sm = 6 cm/sec

18. Khouri et al, JASE, March 2004

19. Doppler Tissue Imaging (DTI) • E/Ea ratio – correlates well with LV filling pressure • E/Ea ratio > 15 • Highly specific for elevated LA pressure • E/Ea < 8 • Sensitive for normal LA pressure Khouri et al, JASE March 2004 E/Ea ratio < 10 - PCWP < 15 mmHg E/Ea ratio > 15 - PCWP > 20 mmHg Nagueh et al. Circulation. 2000

20. Doppler Assessment of LV filling pressures in patients with AF Hemodynamic monitoring using Echo, De Backer, 2011

21. Measurement of pulmonary artery pressure

22. Pulmonary Hypertension

23. Emergency Echocardiography: RV systolic overload • Elevated right ventricular afterload leading to pulmonary hypertension and right heart failure • Echocardiographic features: • Dilated pulmonary artery, right ventricle and right atrium • Hypokinetic right ventricle • Moderate to severe TR with elevated pulmonary systolic arterial pressure • Systolic septal flattening • No significant left heart abnormality

24. Pulmonary artery mass Parasternal short-axis view at the AV level showing the mobile echogenic density within the pulmonary artery Apical 4-chamber view

25. RVEF by 3D Echocardiography Full-volume reconstruction of the right ventricle with EF computation

26. ER Echocardiography: Chest Trauma Echocardiographic findings to look for: • Rupture of cardiac structures (valves and myocardium) • Myocardial contusion (RWMA of the anterior right-sided structures) • Pericardial effusion • Aortic rupture or intimal tear (TEE maybe useful if not contraindicated) • Ruptured coronary sinus of Valsalva

27. Traumatic RCSOV • Ruptured coronary sinus of valsalva due to stabbing TEE with color flow doppler demonstrating the mosaic color flow across the rupture site

28. Assessment of volume status and responsiveness to fluid challenge • Hypotensive or patients in circulatory shock due to hypovelemia or sepsis • IVC diameter could be a good estimate of CVP • SVC and IVC diameter changes in ventilated patients can predict patients’ fluid responsiveness • Respiratory changes in aortic blood flow VTI separate responders from non-responder patients to fluid challenge

29. Assessment of volume status • CVP can be estimated by the size of IVC INSPIRAT EXPIRATI IVC is virtually collapsed during inspiration Hemodynamic monitoring using Echo, De Backer, 2011

30. IVC diameter changes during mechanical ventilation ins exp Collapsibility index can be calculated by measuring the largest and smallest diameters Hemodynamic monitoring using Echo, De Backer, 2011

31. SVC collapsibility in ventilated patients No change during mechanical insufflation Large diameter changes during mechanical insufflation indicate a responder patient to fluid challenge Hemodynamic monitoring using Echo, De Backer, 2011

32. Response to fluid challenge: Stroke volume monitoring 500 ml infused SV 65 ml Hemodynamic monitoring using Echo, De Backer, 2011 SV 38 ml

33. Cardiac volume and filling pressures 70 ml 65 ml 38 ml Restriction to filling Normalized profile Abnormal relaxation Hemodynamic monitoring using Echo, De Backer, 2011

34. Emergency Echocardiography Transthoracic or Transesophageal Echocardiography ? • TTE should be the first-line diagnotic procedure over TEE due to its versatility, availability and tolerance. • TEE is the procedure of choice in the assessment of circulatory failure complicating peri-operative course. • TEE is needed when TTE image quality is inadequate as in ventilated patients, COPD and obese patients.

35. Myocardial Contrast Echocardiography in the ER and ICU settings

36. 3D echo for LV analysis Full-volume reconstruction of the LV with EF computation

37. Summary • Echocardiographic examination in the emergency room can facilitate prompt diagnosis of aortic pathology, pulmonary embolism, myocardial ischemia or infarction and its complication, as well as unexplained hypotension. • Echocardiography remains an important diagnostic tool in the evaluation of patients with circulatory or respiratory failure in critical care setting.

38. In ICU setting, echocardiography plays an essential role in ensuring prompt and correct diagnosis, as well as in hemodynamic monitoring. • Application of new technological advances like myocardial contrast echocardiography, tissue Doppler imaging and 3D echocardiography improves the capabilities of echocardiography in emergency and critical care settings.

39. Thank you

40. RV systolic function assessment • Visual inspection of RV free-wall motion and tricuspid annulus motion • TAPSE • Tissue Doppler imaging • RV fractional area change • RV ejection fraction by 3D echo

41. Aortic blood flow respiratory variation INSPIRATION EXPIRATION Large respiratory change indicates positive response to fluid infusion Hemodynamic monitoring using Echo, De Backer, 2011

42. Emergency Echocardiography Unexplained hypotension, syncope and arrhythmia • Pericardial effusion with tamponade • Hypovolemia/ sepsis • Segmental or global hypokinesia with depressed systolic function • Aortic stenosis • Hypertrophic obstructive cardiomyopathy

43. Assessment of LV filling pressure Color M-mode Vp Tissue Doppler (Ea)

44. Massive pericardial effusion Parasternal short-axis view at the mid-LV level showing the pericardial effusion Apical 4-chamber view showing the pericardial effusion

45. 3D Echocardiography in the Emergency Room • Accurate and reproducible ventricular function assessment (LV and RV) – volume and ejection fraction • Assessment of valvular pathology

46. RAP as estimated by IVC size

47. Measurement of Pulmonary Arterial Pressure PASP = 4 X (TR jet velocity)2 + RAP PAEDP = 4 X (PR jet end-diastolic velocity)2 +RAP Mean PAP = 4 X (PR jet peak velocity)2 or 80 – RVOT AT/2

48. Responsiveness to Fluid Challenge Parameters to monitor: • IVC diameter change on ventilator insufflation (TTE) • SVC diameter change on ventilator insufflation (TEE) • Aortic blood flow respiratory variation

49. dP/dt using MR jet

50. Left Ventricular Volume (M-mode) Stroke volume (SV) = LVEDV – LVESV Cardiac Output (CO) = SV x HR 1000 Cardiac Index (CI) = C O BSA Where: LVEDV= end diastolic volume LVESV= end systolic volume HR = heart rate 1000 = conversion of cc to liters BSA = body surface area