Emergency Ultrasound (EUS)教學(6)

重點式急診心臟超音波之應用
新光醫院急診醫學科
陳國智醫師
中華民國醫用超音波學會指導醫師
 臨床情境
• 64歲女性，呼吸窘迫
• BP 161/101; HR 136
SpO2 94% (NRM)
• PE:
– Diffuse exp. Wheezing
– JVD (-)
– LE edema (-)

• 請問你該怎麼辦 ?

• 急診超音波在此能提供
什麼幫忙?
Cardiac Anatomy
Heart Anatomy
Thoracic Cavity
Cardiac Axes
心臟超音波影像認識
Transducer consideration
Classic routes of heart
Subxiphoid Four-Chamber View
Subxiphoid Short-Axis View
Subxiphoid Long-Axis View
(IVC view)
 Central Venous Pressure
IVC size for volume assessment
IVC size (cm) Resp. change RA pressure
(cm)
<1.5 Total collapse 0-5
1.5-2.5 >50% collapse 5-10
1.5-2.5 <50% collapse 11-15 (>10)
>2.5 <50% collapse 16-20
>2.5 No change >20
IVC size assessment
Parasternal Long-Axis View
Parasternal Short-Axis View
Parasternal Short-Axis View
papillary muscle level
Parasternal Short-Axis View
mitral valve level
Parasternal Short-Axis View
aortic valve level
Mercedes Benz sign
Apical Four-Chamber View
Apical Two-Chamber View
Suprasternal View
Two-Dimensional Measurement
Two-Dimensional Measurement
M-Mode Left Ventricle
 LV systolic function
• LV systolic funciton
– Ejection fraction
– FS=(LVDd-LVSd)/LVDd
– EF=FS * 2
• EF
– >50%
• normal
– 30-50%
• moderate depressed
– <30%
• severely depressed
• Poor LV is often
coupled with a dilated
IVC
Color Doppler Flow
重點式急診心臟超音波

適應症和限制
 Primary Indications
• Detection of pericardial effusion and/or
tamponade
• Evaluation of gross cardiac activity during
CPR
• Evaluation of global LV systolic function
 Secondary Indications
• Gross evaluation of intravascular volume
status and cardiac preload
• Indentify acute RV dysfunction and/or
acute pul. HTN for chest pain / dyspnea/or
hemodynamic instability
• Pericardiocentesis guidance
 Limitations for EUS
• Focal wall motion abnormality
• Diastolic dysfunction
• Valvular abnormalities and function
• Intracardiac mass or thrombus, ventricular
aneurysm, septal defect, AD, myocarditis,
HCM, and vegetation
 Technical limitations
• Thorax abnormalities
• Pulmonary hyperinflation
• Obesity
• Patient can’t cooperate
• Subcutaneous emphysema
 Key component
• Evaluation of pericardial effusion
– Anechoic or hypoechoic fluid
– Complex echogenicity: inflammation, infection,
malignancy, hemorrhage
• Classification
– None
– Small, <10 mm in width in dastole, non-
circumferential
– Moderate, circumferential, not greater than 10 mm
– Large, 10-20mm in width
– Very large, > 20 mm and/or evidence of tamponade
Pericardial Effusion
Pericardial Effusion
 Key component
• Echocardiographic evidence of tamponade
– Diastolic collapse of any chamber in the
presence of moderate or large effusion
– Hemodynamic instability with a moderate or
large pericardial effuion
Cardiac Tamponade
 US 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
Technique
 Pericardial Effusion / Tamponade
• Tamponade
– Clinical diagnosis
– Circulatory collapse due to pericardial effusion
• Subxiphoid approach is the best window
– Effusion location – inferior & posterior
• Echo evidence of tamponade
– Diastolic collapse of the right side of the heart
– Plethoric IVC without inspiratory collapse
 Key component
• Evaluation of gross cardiac motion (CPR)
– Terminal cardiac dysfunction
• Global ventricular hypokinesis
• Incomplete systolic valve closure
• Absence of valve motion
• Absence of ventricular motion
• Intracardiac gel-like densities
– Lack of mechanical cardiac activity
• Gravest of prognosis
 Chest pain then code
• 55 y/o male suffered witnessed V-fib arrest
in the ED
• ALS protocol - restoration of perfusing
rhythm
• Persistent hypotension
• ED ECHO was performed
 Direct Visualization
• Is there effective myocardial
contractility?
– Asystole
– Myocardial “twitch”
– Hypokinesis
– Normal
• Is there a pericardial effusion?
 ECHO in PEA
• Perform ECHO during “quick look”
and in pulse checks
• Change management based on
“positive” findings
• Pericardial tamponade
– Pericardiocentesis
• Hyperdynamic cardiac wall motion
– Volume resuscitate
 ECHO in PEA
• RV dilatation
– Hypoxic?? – Likely PE
– ECG – IMI with RV infarct?
• Profound hypokinesis
– Inotropic support
• Asystole
– Follow ACLS protocols (for now)
– Early data suggesting poor prognosis
Heart evaluation

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Resuscitation (2008) 76, 198—206
 Key component
• Evaluation of global cardiac function
– Normal LV systolic funciton (EF > 50%)
– Moderately depressed (EF 30-50%)
– Severely depressed (EF < 30%)
Myocardial Ischemia
LV wall segments
Chronic LV infarction
Dilated left ventricle
 RV strain
• Normal RV: LV ratio = 0.6 : 1
• RV strain
– RV hypokinesis
– Paradoxical septal motion
• Cause
– Pulmonary embolism
– Chronic lung disease
– Pulmonary hypertension
– Pulmonary stenosis
• RV free wall > 5 mm  chronic condition
Massive Pulmonary Embolism
Proximal Aortic Dissection
Type A aortic dissection
Aortic dissection (TEE)
Ascending Aortic Aneurysm
LV Thrombus
Vegetations
Ventricular Hypertrophy
Myxoma
Focus Assessed Transthoracic Echo (FATE)
 FATE protocol
• Exclude obvious pathology
• Assess wall thickness and dimension of
chambers
• Assess contractility
• Visualize pleural on both sides
• Relate the information to the clinical
context
 Pitfalls
1. Contraindications
2. Inability to obtain adequate views
3. Reversed orientation
4. Fluid versus blood clot or fat
5. Gain issues
6. Depth
7. Dynamic range
Orientation Review
 Summary
• Bedside ECHO can help assess:
– Overall cardiac wall motion
– Assess preload status
– Identify clinically significant pericardial effusions
• Useful in the assessment of the patient with:
– Unexplained hypotension
– Dyspnea
– Thoracic trauma