II. Indications: Emergency Echocardiogram

  1. Emergency Echocardiography (or Focused Ultrasound Examination) does not replace a complete Echocardiogram
    1. Emergency Echocardiogram is done to answer specific emergency related questions
    2. Cardiac Arrest evaluation (echo during pulse checks)
      1. Pericardial Effusion
      2. Cardiac activity
    3. Advanced skills
      1. Heart wall motion and cardiac contractility
      2. Valvular abnormalities
    4. Overall Approach (Mnemonic: 5Es)
      1. Ejection Fraction (estimate cardiac contractility or EPSS)
      2. Equality (right heart size in comparison with left)
      3. Effusion (Pericardial Effusion)
      4. Entrance (Inferior Vena Cava Ultrasound)
      5. Exit (aortic root measurement)
  2. Cardiac Arrest
    1. Cardiac standstill
      1. Evaluate during pulse checks during CPR
      2. A flicker of heart wall motion beyond mitral valve movement may signal cardiac activity
      3. Distinguish from Ventricular Fibrillation appearance (shimmering appearance of ventricular wall)
      4. Distinguish from lung excursion with Positive Pressure Ventilation (stop PPV to visualize heart activity)
      5. Prolonged cardiac standstill may demonstrate congealed blood in ventricle
      6. Associated with little to no chance of ROSC and survival (helps direct cessation of code)
        1. Blaivas (2001) Acad Emerg Med 8:616 [PubMed]
        2. Salen (2001) Acad Emerg Med 8(6): 610-5 [PubMed]
    2. Identify reversible causes of PEA
      1. Cardiac Tamponade (Pericardial Effusion and right ventricular collapse in diastole)
      2. Hypovolemic Shock (hyperdynamic heart with with small ventricular chamber)
      3. Myocardial Infarction (new wall motion abnormality, decreased contractility or EF)
      4. Pulmonary Embolism (consider empiric PE Thrombolysis)
        1. See Echocardiogram in PE
        2. See Focused Lower Extremity Venous Ultrasound
        3. Acute dilated right ventricular (RV) chamber
          1. Right ventricle diameter is normally two thirds the left ventricular diameter
        4. Acute RV dilation findings (contrast with chronic RV dilation of COPD and other Cor Pulmonale)
          1. Right ventricular free wall thickness <0.5 cm in end diastole
        5. McConnell's Sign
          1. Dilated right ventricle with RV free wall akinesis and normal apical contractions
        6. References
          1. Swaminathan and Avila in Herbert (2020) EM:Rap 20(5):10
  3. Shock or Hypotension
    1. See RUSH Protocol
  4. Acute Dyspnea
  5. Pulmonary Embolism
    1. Evaluate right heart function
    2. Dilated right ventricle and right atrium
    3. D-Sign (interventricular septum bows into the left ventricle with contractions)
  6. Trauma
    1. See FAST Exam
  7. Myocardial Infarction
    1. Wall motion abnormalities are very challenging to visualize unless severely diminished
    2. Newer Ultrasound machines and technologies may automate analysis
  8. Ultrasound-Guided Pericardiocentesis
  9. Pericardial Effusion
  10. Thoracic Aortic Dissection (Type A)
    1. See Aorta Diameter Measurement on PLAX View

III. Background: Basics

  1. Probe Direction Indicator
    1. Issue of confusion on learning Bedside Ultrasound (emergency department and Critical Care)
    2. Cardiac echo is, by convention, performed with direction indicator on the screen right
      1. Provider should direct the indicator when transverse to point to 3:00 (not 9:00)
      2. Ultrasound machines when on cardiac preset
        1. Automatically move the screen indicator to screen right
      3. All other regional Ultrasound conventions and machine presets (non-cardiac)
        1. Automatically move the indicator to screen left (and pointing to 9:00 position)
    3. Follow simple rule: Probe indicator direction should match the screen indicator direction
      1. Applies when screen directly in front of operator
      2. Check the probe indicators screen position
      3. Observe the screen while tapping or drawing finger across the indicator end
  2. Use Cardiac Phased-Array transducer (1-5 MHz)
    1. Use cardiac preset
      1. Transducer marker corresponds to screen right (contrast with other presets where marker is on screen left)
    2. Optimize the resolution for the intended depth
      1. Deeper structures require lower frequency, often labeled as "penetration mode" (lower resolution)
      2. Superficial structures may be imaged with higher frequency, labeled as "general mode" (and higher resolution)
    3. Faster frame rate (>20 fps is ideal) to catch dynamic images throughout Cardiac Cycle
      1. Image as shallow as possible (reduce depth)
      2. Narrow the sector (narrow the pie shaped wedge of Ultrasound signals)
      3. Zoom to the area of interest
    4. Avoid using "gain control" to improve image definition
      1. Gain control only adjusts "receiver gain" of the signals that are returning to the scan head (1% of those sent)
      2. Image resolution is based on scan frequency, which is sending signals
      3. Modifying the "receiver gain" only further degrades the resolution
      4. Only after optimizing resolution for depth, should the gain control be used to modify the image brightness
        1. Use the receiver gain only to "darken the snow" or "whiten the landmarks"
  3. Heart axis
    1. Longitudinal refers to long orientation of left ventricle (right Shoulder to left hip)
    2. Longitudinal view will be more horizontal in obese patients and more vertical in thin, tall patients
  4. Most patients will have at least one adequate view to visualize heart function
    1. Technique for a single view can be modified to visualize most structures
    2. Quality of view may be inversely proportional to body habitus (i.e. Obesity degrades the view)
      1. However, do not pre-adjust machine settings based on habitus alone
      2. Some larger patients have excellent cardiac windows with wide open rib spaces
    3. Subxiphoid Echocardiogram View
      1. Best view in Asthma and COPD
      2. Preferred view during CPR to prevent interruptions
    4. Parasternal long axis
      1. Best view in pregnancy, Obesity and Ascites
    5. Apical Four Chamber Echocardiogram View
      1. May offer a four chamber view, when subcostal view is difficult due to intestinal gas or Obesity
  5. Grading cardiac contractility (systolic function, ejection fraction)
    1. Severely reduced (EF<30%)
    2. Mildly reduced (EF 30-55%)
    3. Normal (EF 55-65%)
    4. Hyperdynamic (EF >65%)

IV. Background: Doppler

VI. Resources

  1. Virtual Thransthoracic Echo
    1. http://pie.med.utoronto.ca/TTE/TTE_content/standardViews.html
  2. Sub-xiphoid View Video (SonoSite)
    1. http://www.youtube.com/watch?v=1UJ6RodOSTw
  3. Apical 4-Chamber View Video (SonoSite)
    1. http://www.youtube.com/watch?v=_eHZz-OCc_M
  4. Parasternal Long Axis View Video (Sonosite)
    1. http://www.youtube.com/watch?v=4qerzEW_ASU
  5. Parasternal Short Axis View Video (SonoSite)
    1. http://www.youtube.com/watch?v=EaLuCBXXINg
  6. Suprasternal Notch View Video (Sonosite)
    1. http://www.youtube.com/watch?v=Mkc6tUVRgKo
  7. Inferior Vena Cava Ultrasound Video (SonoSite)
    1. http://www.youtube.com/watch?v=ci9W4MvyMHI
  8. Echocardiographer
    1. http://echocardiographer.org/

VII. References

  1. Jordan (2019) Cardiac Ultrasound Protocol Manual, Gulfcoast Ultrasound, p 13-22
  2. Reynolds (2018) The Echocardiographer's Pocket Reference, Arizona Heart Association, p. 323-4
  3. Palma, Bourque and Jordan (2019) Introduction to Adult Echo Ultrasound Conference, GulfCoast Ultrasound, St. Petersburg
  4. Mateer and Jorgensen (2012) Introduction and Advanced Emergency Medicine Ultrasound Conference, GulfCoast Ultrasound, St. Pete's Beach
  5. Noble (2011) Emergency and Critical CareUltrasound, Cambridge University Press, New York, p. 61-88
  6. Orman, Dawson and Mallin in Majoewsky (2013) EM:Rap 13(1): 4-6
  7. Reardon (2011) Pocket Atlas Emergency Ultrasound, McGraw Hill, New York, p. 61-106

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Echocardiography (C0013516)

Definition (NCI) A test that uses high-frequency sound waves (ultrasound) to create an image of the heart.
Definition (NCI_NCI-GLOSS) A procedure that uses ultrasonic waves directed over the chest wall to obtain a graphic record of the heart's position, motion of the walls, or internal parts such as the valves.
Definition (NCI_CDISC) A procedure that uses high-frequency sound waves (ultrasound) to create an image of the heart.
Definition (MSH) Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic.
Definition (CSP) graphic registration of the frequency and intensity of heart sounds.
Definition (CSP) ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues; the standard approach is transthoracic.
Concepts Diagnostic Procedure (T060)
MSH D004452
ICD9 88.72
ICD10 1942
SnomedCT 169242007, 169239001, 146458000, 40701008
CPT 1013050
LNC LP6171-5, LA7215-2, LA11845-7
English Echocardiography, US heart scan NOS (procedure), heart sonography, ECHOCARDIOGR TRANSTHORACIC, ECHOCARDIOGR, TRANSTHORACIC ECHOCARDIOG, US heart scan NOS, sound measurement, echocardiogram (procedure), Echocardiography, Transthoracic, Transthoracic Echocardiography, echocardiogram, Dx ultrasound-heart, Ultrasound of heart, echocardiograms, cardiac echo, heart ultrasound, transthoracic echocardiography, Ultrasound heart scan NOS, Ultrasound heart scan NOS (procedure), Echocardiography Procedures, echocardiography, ECHOCARDIOGRAM, Diagnostic ultrasound of heart, Echocardiographic procedure, Cardiac US scan, Cardiac echo, Echocardiogram, US scan of heart, US heart scan, Echocardiography (procedure), Ultrasonography of heart, Echocardiography, NOS, Ultrasonography of heart, NOS, Echocardiographic procedure, NOS
Italian Ecocardiogramma, Ecocardiografia transtoracica, Ecocardiografia
Dutch echocardiografie, echocardiogram, Echocardiografie, Echocardiografie, transthoracale
French Echocardiographie, Échocardiographie par voie transthoracique, Échocardiographie transthoracique, Échographie cardiaque, Echocardiogramme, Échocardiographie, Ultrasonocardiographie
Japanese 心エコー像, 心エコー, シンエコーゾウ, シンエコー, Mモード心エコー図法, UCG法, エコー心拍動記録, エコー心拍動記録法, コントラスト心エコー図, 心エコー図法-二次元, 超音波心エコー法, 超音波心臓検査, 超音波心臓検査法, 二次元心エコー図, エコーカルジオグラフィー, 心エコー法, 超音波心エコー, 心臓超音波検査, コントラスト心エコー図法, 心エコー図-Mモード, 心エコー図法-コントラスト, 二次元心エコー図法, 横断面心エコー図, 心エコー図法, 心エコー図法-横断面, 心超音波図法, 横断面心エコー図法, 心エコー図-横断面, 心エコー図-二次元, 超音波診断-心臓, 心エコー図法-Mモード, 超音波カルジオグラフィ, エコー心拍記録, エコー心拍記録法, 心エコー図-コントラスト, 心エコー図, Mモード心エコー図
Swedish Ekokardiografi
Czech echokardiografie, Echokardiogram, Echokardiografie
Finnish Kaikukardiografia
Polish Echokardiografia, Ultrasonokardiografia
Hungarian Echokardiográfia, Echokardiogram
Norwegian Ultralydundersøkelse av hjertet, Ekkokardiografi, Hjerteultralyd, transtorakal
Spanish ecografía cardíaca, SAI, ecografía cardíaca, SAI (procedimiento), ecocardiografía (procedimiento), ecocardiografía, ecografía de corazón, ecografía diagnóstica de corazón, procedimiento ecocardiográfico, Ecocardiograma, Ecocardiografía, Ecocardiografía Transtorácica
Portuguese Ecocardiograma, Ecocardiografia, Ecocardiografia Transtorácica
German Echokardiogramm, Echokardiographie, transthorakale, Echokardiographie, Sonokardiographie, Transthorakale Echokardiographie, Ultraschallkardiographie, UKG

Ontology: Transthoracic echocardiography (C0430462)

Definition (NCI) A non-invasive cardiac ultrasound performed by placing the transducer on the chest.
Concepts Diagnostic Procedure (T060)
SnomedCT 433236007, 252418006
Dutch transthoracaal echocardiogram, transthoracale echocardiografie
English Transthoracic echocardiography, Transthoracic echocardiography (procedure), Transthoracic Echocardiography, transthoracic echocardiogram, transthoracic echocardiography, echo transthoracic (procedure), echo transthoracic, Transthoracic echocardiogram
French Echocardiographie transthoracique, Echocardiogramme transthoracique
German transthorakales Echokardiogramm, transthorakale Echokardiographie
Italian Ecocardiografia transtoracica, Ecocardiogramma transtoracico
Portuguese Ecocardiograma transtorácico, Ecocardiografia transtorácica
Spanish Ecocardiografía transtorácica, ecocardiograma transtorácico (procedimiento), ecocardiograma transtorácico, ecocardiografía transtorácica, ecocardiografía transtorácica (procedimiento)
Japanese 経胸壁心エコー, 経胸壁心エコー像, ケイキョウヘキシンエコー, ケイキョウヘキシンエコーゾウ
Czech Transtorakální echokardiografie, Transtorakální echokardiogram
Hungarian Transthoracalis echocardiographia, Transthoracalis echocardiogram

Ontology: cardiac ultrasound (C1655737)

Concepts Diagnostic Procedure (T060)
LNC LP29672-0, MTHU000045
English CARD.US, Cardiac ultrasound (was US.ECHO), Ultrasound;cardiac, cardiac ultrasound