II. Indications: Emergency Echocardiogram
- Emergency Echocardiography (or Focused Ultrasound Examination) does not replace a complete Echocardiogram
- Emergency Echocardiogram is done to answer specific emergency related questions
- Cardiac Arrest evaluation (echo during pulse checks)
- Pericardial Effusion
- Cardiac activity
- Advanced skills
- Heart wall motion and cardiac contractility
- Valvular abnormalities
- Overall Approach (Mnemonic: 5Es)
- Ejection Fraction (estimate cardiac contractility or EPSS)
- Equality (right heart size in comparison with left)
- Effusion (Pericardial Effusion)
- Entrance (Inferior Vena Cava Ultrasound)
- Exit (aortic root measurement)
-
Cardiac Arrest
- Cardiac standstill
- Evaluate during pulse checks during CPR
- A flicker of heart wall motion beyond mitral valve movement may signal cardiac activity
- Distinguish from Ventricular Fibrillation appearance (shimmering appearance of ventricular wall)
- Distinguish from lung excursion with Positive Pressure Ventilation (stop PPV to visualize heart activity)
- Prolonged cardiac standstill may demonstrate congealed blood in ventricle
- Associated with little to no chance of ROSC and survival (helps direct cessation of code)
- Identify reversible causes of PEA
- Cardiac Tamponade (Pericardial Effusion and right ventricular collapse in diastole)
- Hypovolemic Shock (hyperdynamic heart with with small ventricular chamber)
- Myocardial Infarction (new wall motion abnormality, decreased contractility or EF)
- Pulmonary Embolism (consider empiric PE Thrombolysis)
- See Echocardiogram in PE
- See Focused Lower Extremity Venous Ultrasound
- Acute dilated right ventricular (RV) chamber
- Right ventricle diameter is normally two thirds the left ventricular diameter
- Acute RV dilation findings (contrast with chronic RV dilation of COPD and other Cor Pulmonale)
- Right ventricular free wall thickness <0.5 cm in end diastole
- McConnell's Sign
- Dilated right ventricle with RV free wall akinesis and normal apical contractions
- References
- Swaminathan and Avila in Herbert (2020) EM:Rap 20(5):10
- Cardiac standstill
-
Shock or Hypotension
- See RUSH Protocol
- Acute Dyspnea
-
Pulmonary Embolism
- Evaluate right heart function
- Dilated right ventricle and right atrium
- D-Sign (interventricular septum bows into the left ventricle with contractions)
-
Trauma
- See FAST Exam
-
Myocardial Infarction
- Wall motion abnormalities are very challenging to visualize unless severely diminished
- Newer Ultrasound machines and technologies may automate analysis
- Ultrasound-Guided Pericardiocentesis
- Pericardial Effusion
- Thoracic Aortic Dissection (Type A)
III. Background: Basics
- Probe Direction Indicator
- Issue of confusion on learning Bedside Ultrasound (emergency department and Critical Care)
- Cardiac echo is, by convention, performed with direction indicator on the screen right
- Provider should direct the indicator when transverse to point to 3:00 (not 9:00)
- Ultrasound machines when on cardiac preset
- Automatically move the screen indicator to screen right
- All other regional Ultrasound conventions and machine presets (non-cardiac)
- Automatically move the indicator to screen left (and pointing to 9:00 position)
- Follow simple rule: Probe indicator direction should match the screen indicator direction
- Applies when screen directly in front of operator
- Check the probe indicators screen position
- Observe the screen while tapping or drawing finger across the indicator end
- Use Cardiac Phased-Array transducer (1-5 MHz)
- Use cardiac preset
- Transducer marker corresponds to screen right (contrast with other presets where marker is on screen left)
- Optimize the resolution for the intended depth
- Deeper structures require lower frequency, often labeled as "penetration mode" (lower resolution)
- Superficial structures may be imaged with higher frequency, labeled as "general mode" (and higher resolution)
- Faster frame rate (>20 fps is ideal) to catch dynamic images throughout Cardiac Cycle
- Image as shallow as possible (reduce depth)
- Narrow the sector (narrow the pie shaped wedge of Ultrasound signals)
- Zoom to the area of interest
- Avoid using "gain control" to improve image definition
- Gain control only adjusts "receiver gain" of the signals that are returning to the scan head (1% of those sent)
- Image resolution is based on scan frequency, which is sending signals
- Modifying the "receiver gain" only further degrades the resolution
- Only after optimizing resolution for depth, should the gain control be used to modify the image brightness
- Use the receiver gain only to "darken the snow" or "whiten the landmarks"
- Use cardiac preset
- Heart axis
- Longitudinal refers to long orientation of left ventricle (right Shoulder to left hip)
- Longitudinal view will be more horizontal in obese patients and more vertical in thin, tall patients
- Most patients will have at least one adequate view to visualize heart function
- Technique for a single view can be modified to visualize most structures
- Quality of view may be inversely proportional to body habitus (i.e. Obesity degrades the view)
- However, do not pre-adjust machine settings based on habitus alone
- Some larger patients have excellent cardiac windows with wide open rib spaces
- Subxiphoid Echocardiogram View
- Parasternal long axis
- Apical Four Chamber Echocardiogram View
- May offer a four chamber view, when subcostal view is difficult due to intestinal gas or Obesity
- Grading cardiac contractility (systolic function, ejection fraction)
- Severely reduced (EF<30%)
- Mildly reduced (EF 30-55%)
- Normal (EF 55-65%)
- Hyperdynamic (EF >65%)
IV. Background: Doppler
- See Doppler Echocardiogram
- Pulsed Wave Doppler (PW)
- Continuous Wave Doppler (CW)
- Color Flow Imaging (Color Doppler Imaging or CDI)
V. Views: General
VI. Resources
- Virtual Thransthoracic Echo
- Sub-xiphoid View Video (SonoSite)
- Apical 4-Chamber View Video (SonoSite)
- Parasternal Long Axis View Video (Sonosite)
- Parasternal Short Axis View Video (SonoSite)
- Suprasternal Notch View Video (Sonosite)
- Inferior Vena Cava Ultrasound Video (SonoSite)
- Echocardiographer
VII. References
- Jordan (2019) Cardiac Ultrasound Protocol Manual, Gulfcoast Ultrasound, p 13-22
- Reynolds (2018) The Echocardiographer's Pocket Reference, Arizona Heart Association, p. 323-4
- Palma, Bourque and Jordan (2019) Introduction to Adult Echo Ultrasound Conference, GulfCoast Ultrasound, St. Petersburg
- Mateer and Jorgensen (2012) Introduction and Advanced Emergency Medicine Ultrasound Conference, GulfCoast Ultrasound, St. Pete's Beach
- Noble (2011) Emergency and Critical CareUltrasound, Cambridge University Press, New York, p. 61-88
- Orman, Dawson and Mallin in Majoewsky (2013) EM:Rap 13(1): 4-6
- Reardon (2011) Pocket Atlas Emergency Ultrasound, McGraw Hill, New York, p. 61-106
Images: Related links to external sites (from Bing)
Related Studies
| 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 |
| HL7 | EC |
| 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, ｼﾝｴｺｰｿﾞｳ, 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 |
| Russian | EKHOKARDIOGRAFIIA, KARDIOGRAFIIA UL'TRAZVUKOVAIA, UL'TRAZVUKOVAIA KARDIOGRAFIIA, EKHOKARDIOGRAFIIA DVUKHMERNAIA, KONTRASTNAIA EKHOKARDIOGRAFIIA, TRANSTORAKAL'NAIA EKHOKARDIOGRAFIIA, КАРДИОГРАФИЯ УЛЬТРАЗВУКОВАЯ, КОНТРАСТНАЯ ЭХОКАРДИОГРАФИЯ, ТРАНСТОРАКАЛЬНАЯ ЭХОКАРДИОГРАФИЯ, УЛЬТРАЗВУКОВАЯ КАРДИОГРАФИЯ, ЭХОКАРДИОГРАФИЯ, ЭХОКАРДИОГРАФИЯ ДВУХМЕРНАЯ |
| Croatian | EHOKARDIOGRAFIJA |
| 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ｿﾞｳ |
| 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 |
