Echocardiography for Emergency Physician :

The Future Stethoscope

Fajar Perdhana
Department of Anesthesiology and Reanimation
Dr. Soetomo General Hospital-Faculty of Medicine Airlangga University
Surabaya
History
• It was unimaginable 100 years ago to be able to draw a
picture from sound
“ The medical profession was unlikely ever to start using
stethoscope because its beneficial application requires much
time and gives a good bit of trouble”
-The Times 1834-

• Ultrasound, Which is our future stethoscope, has passed

through the same story
• Since its inception over 60 years ago, echocardiography has
remained largely the province of the cardiologist

• In recent years, the application of echocardiography has

extended to the diagnosis and monitoring of critically ill
patients in the general ICU  Goal-directed Echo

• TTE performed at the patients bedside  answer spesific

clinical questions

• The principal role is the time sensitive assessment of the

symptomatic patient
• “Stethoscope of the future”
• Rapid visualization of cardiac structures and
potential pathology
• More sensitive & specific than physical exam,
ECG or CXR
4
 Evolution in Echocardiography

NOVICE - CARDIOLOGIST EXPERT

- CARDIAC ANESTHESIOLOGIST
- SURGEON
- ED PHYSICIAN
- INTENSIVIST ANESTHESIOLOGIST
• It is an safe, easy, inexpensive, noninvasive, no radiation and
portable technique, which can be rapidly performed at
bedside
• Since the physician who performs echo may be the same who
is managing the patient, the echo data can be readily used to
speed up the decision-making process (Neskovic et al. 2013)
• “..echo must be available 24/7..”
 Full range of
cardiac diagnosis
and complete
hemodynamic
evaluation

Detect gross valvular dysfunction

Assessment of fluid responsiveness
Measure CO & sPAP
Quantitative LV function assessment (EF)

Detect large pericardial effusion

Recognize marked RV dilatation
Measure Inferior Vena Cava diameter
Recognize severely abnormal LV contractility
Who can do ECHO??
• Emergency echocardiography should be performed by anyone who
knows how to get valuable information
• Use it in the decision-making process
• ‘Know how’ includes:
• ability to obtain adequate images (imaging technique)
• ability to interpret them in the specific clinical context
(reading/interpretation).
 Improperly acquired and/or poor-quality images may result in
inaccurate reading, with misleading and potentially dangerous
conclusions (Neskovic et al.2013)
 LV Failure

Cardiogenic
RV Failure

Hypovolemia

Tamponade

Obstructive
Pulmonal Emboli

Sepsis

Distributive

Anaphylactic
Goal-directed Echocardiography
• Defined as a rapid and focused hemodynamic assessment,
opening the doors to a quick and specific therapeutic
strategy
• Vignon and colleagues  focused training in goal-oriented
 six simple clinical issues: (Vignon et al. 2007)
• LV systolic dysfunction,
• LV dilatation,
• Right ventricular (RV) dilatation,
• Pericardial effusion,
• Cardiac tamponade, and
• Pleural effusion (8).
Goal-directed Echocardiography
• Recent studies inform a routine, standardized, goal-directed
approach.
• McLean and Huang defined the RACE (Rapid Assessment by
Cardiac Echo) : (McLean and Huang. 2012)
• Approach Five views (parasternal long- and short-axis, apical four chamber,
subcostal and IVC)
• Four questions constitute the core of the evaluation : (1) How is LV function?
(2) How is RV function? (3) Is there pericardial effusion? (4) And, finally, how
is fluid status?
The main hemodynamic patterns to be identified and
how to do so using goal-directed echocardiography
 The 4 Question
• What is the left heart function?
• What is the right heart function?
• With attention to emboli pulmonal
• Is there any evidence of pericardial effusion and
cardiac tamponade?
• What is the fluid status?
“You can diagnose within minute”
What is the left heart function?

PLAX PLAX
PSAX PSAX
What is the right heart function?

PLAX PLAX
A4C A4C
PSAX PSAX
PULMONAL EMBOLI
A4C A4C
 Pulmonal emboli

Mc Connell’s Sign
D-shaped LV

RA/RV Dilated
Is there any evidence of pericardial effusion
and cardiac tamponade ?
Subcostal 4C Subcostal 4C
A4C PLAX
What is the fluid status?

PSAX Sub Costal IVC

Collapsibility Index : (Dmax-Dmin)/ Dmax X 100%
 Spontaneous breathing (>50%)
Distensibility Index : (Dmax-Dmin)/Dmin X 100%
 Mechanical ventilation (>18%)
A5C
Velocity Time Integral (VTI)
• VTi variation  hallmark of fluid responsivenesss status
• A VTI variation of > 12% predicts fluid responsiveness
(defined as an increase in CO by at least 15% in response to a
standard fluid bolus)
• sensitivity of 100% and a specificity of 89%.
• The maximum and minimum peak velocities (Vmax) is an
alternative to tracing the VTI. This is quicker and easier, and
again.
• > 12% variation suggests fluid responsiveness.
30
31
Passive Leg Raising (PLR)
• Semifowler 45° Position  Leg
raising 45°.
• Pre and post PLR Ao VTI measurement
 A5C using PW Doppler.
• PLR is dynamic parameter
• Increase SV > 12 %  fluid
responsiveness
• The PLR maneuver is a simple and
reliable method for evaluating
preload dependency in patients with
circulatory failure
• a significant increase in CO is
observed over the following minutes-
reaching a peak 60-90 s after Levitov A. Cardiol Research and Practice 2012
elevation
CASE…
• Male, 56 yo, W : 65 kg H: 165 cm BSA : 1,72m2
• Refer from previous hospital,
• Diagnose: Submandibula abcess, septic, AKI, pulmonary edema
• Intubated
• Plan source control surgery
• Initial vitals :
• HR : 120x/min BP : 70/40 mmHg Temp : 390C CVP = 10 mmHg
• Tx : Fluid infusion 2000 cc
NE 100 nano
Dopamine 7 gamma
What’s Next???
PLAX PSAX
Subcostal IVC
• Hyperdynamic LV
• LV Kissing
• IVC distensibility Index = 32.5%  >18%
(possible responder)

FLUID!!
After fluid bolus

Time to stop IV Fluid Loading

And still it could not reach MAP target
Cardiac output Measurement
• CO : 5.8 L
• CI : 3.3 L/min/m2
• SVR = 80 (MAP-CVP)/CO
 550 dyn.s/cm5 GOALS :
MAP > 65 mmHg
CI > 2.5
Vasopressin
Subcostal 4Chamber
Conclusion
• Non‐invasive and rapid to initiate, it can be applied at the bedside anytime
during the day or night.
• Echocardiography is perhaps the most single useful tool in the diagnosis
and management of shock, particularly where the etiology is
undifferentiated or multifactorial.
• The role of goal-directed echocardiography in emergency and critical care
setting is continually evolving and becoming accepted as a beneficial
modality in the treatment, care, and monitoring of the critically ill and
emergency patient.
• Proper training is essential for the benefit and accurate diagnosis of
patients.
“Technology is changing patient safety by
moving the ability to report on events to
the ability to prevent negative outcomes”
TERIMA KASIH
• Vieillard-Baron A, Prin S, Chergui K, Dubourg O, Jardin F. Hemodynamic instability in
sepsis: bedside assessment by Doppler echocardiography. Am J Respir Crit Care Med
2003;168:1270–1276.
• Vieillard-Baron A, Slama M, Cholley B, Janvier G, Vignon P. Echocardiography in the
intensive care unit: from evolution to revolution? Intensive Care Med 2008;34:243–249.
• Vincent JL, Rhodes A, Perel A, Martin GS, Della Rocca G, Vallet B, Pinsky MR, Hofer CK,
Teboul JL, de Boode WP, et al. Clinical review: update on hemodynamic monitoring–a
consensus of 16. Crit Care 2011;15:229.
• AN Neskovic et al. Emergency echocardiography: the European Association of
Cardiovascular Imaging recommendations. European Heart Journal – Cardiovascular
Imaging (2013) 14, 1–11
• Vignon P, Dugard A, Abraham J, Belcour D, Gondran G, Pepino F, Marin B, Francois B,
Gastinne H. Focused training for goal-oriented hand- held echocardiography performed
by noncardiologist residents in the intensive care unit. Intensive Care Med
2007;33:1795–1799.
• McLean A, Huang S. Critical care ultrasound manual. Chatswood, Australia: Churchill
Livingstone, Elsevier; 2012.