FOCUS

CR

Low frequency (3~5 MHZ Probe)

CurvedLow frequency (2.53.5 MHZ Probe)

Cardiac probe selection

Small round footprint for scan between ribs 2.5 MHz: above average sized patient 3.5 MHz: average sized patient 5.0 MHz: below average sized patient or child

Primary Indications
Thoraco-abdominal trauma Pulseless Electrical Activity Unexplained hypotension Suspicion of pericardial effusion/tamponade

Secondary Indications
Acute Cardiac Ischemia Pericardiocentesis External pacer capture Transvenous pacer placement

Limitation
Subcutaneous air Pneumopericardium Mechanical ventilation Scanning limited by: Pain/tenderness Spinal immobilization Ongoing procedures

 Narrow intercostal spaces Obesity Muscular chest COPD Calcified rib cartilages Abdominal distention

Anatomy

Ultrasound Image Rules

Black = fluid

blood, effusions, ascites tissue in general

Medium grays = myocardium

White = connective tissue
valves, pericardium

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Ultrasound Image Rules Basic 2D Cardiac Image

Black = Fluid
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Ultrasound Image Rules Basic 2D Cardiac Image

Gray = Myocardium
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Ultrasound Image Rules Basic 2D Cardiac Image

White = connective tissue

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Echo Windows
SS

SS

SC

P A P

SC

A
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Main cardiac views

Parasternal Subcostal Apical

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Subcostal View

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Subcostal View

Illustration by Patrick J Lynch www.infomed.yale.edu 18

Subcostal View

Transducer placement

Desired Image

What the image shows

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IVC view

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IVC vs CVP

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Subcostal View
Pericardial Effusion
Liver
Liver

RA

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Suprasternal Notch View

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Suprasternal Notch View

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Parasternal Long Axis

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Parasternal Long Axis

Transducer placement

Desired Image

What the image shows

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Parasternal Long Axis

Illustration by Patrick J Lynch www.infomed.yale.edu 28

Parasternal Long Axis Diastole

Measure LV diameter - Normal: 57 mm Measure LV walls - Normal: 11 mm Assess for Pericardial Effusion - anterior to RV or
posterior to LV

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Parasternal Long Axis Systole

Measure LA diameter
Normal: 40 mm

Aortic root approx. same size as LA

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Parasternal Short Axis

LA

SA

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Parasternal Short Axis

Illustration by Patrick J Lynch www.infomed.yale.edu 33

Papillary muscle level

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Mitral valve level

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Aortic valve level

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Apical 4 Chamber

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Apical 4 Chamber

Transducer placement

Desired Image

What the image shows

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Apical 4 Chamber

Illustration by Patrick J Lynch www.infomed.yale.edu 40

Apical 2 Chamber

Illustration by Patrick J Lynch www.infomed.yale.edu 41

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Wall Motion
Normal Hyperkinetic Akinetic Dyskinetic: may fail to contract, bulges outward at systole Hypokinetic
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M-Mode
M-line

Motion over Time

TIME

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M-Mode

distance

time
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Color Doppler

Flow toward transducer = RED Flow away from transducer = BLUE

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Size of the Pericardial Effusion

Not Precise Small: confined to posterior space, < 0.5cm Moderate: anterior and posterior, 0.5-2cm (diastole) Large: > 2cm

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Pericardial Fluid: Subcostal

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Tamponade

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McConnell sign

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RV dilatation
RV dilatation COPD with acute Cor Pulmonale RCA occlusion with RV infarction (AMI) Massive Pulmonary Emboli

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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

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Technique

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FOCUSED CARDIAC ULTRASOUND VERSUS COMPREHENSIVE ECHOCARDIOGRAPHY

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 Other pathologic diagnoses (intracardiac masses, LV thrombus, valvular dysfunction, regional wall motion abnormalities, endocarditis, aortic dissection) may be suspected on FOCUS, but additional evaluation, including referral for comprehensive echocardiography or cardiology consultation

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 Comprehensive echocardiographic examination or other imaging modalities are recommended in any case in which the focused findings and clinical presentations are discordant

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Clinical Applications of FOCUS

Cardiac trauma -Blunt -Penetrating One part of FAST exam Hemopericardium Contusion Difficult !!

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Stab wound to the chest

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Blunt Cardiac Trauma

Cardiac contusion
Cardiac rupture Valvular disruption Aortic disruption/dissection

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Blunt Cardiac Trauma

Pericardial effusion Assess for wall motion abnormality

RV dyskinesis (takes the first hit)

Assess thoracic aorta:

Hematoma Intimal flap Abnormal contour

Valvular dysfunction or septal rupture

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Blunt Cardiac Trauma

Assess thoracic aorta

Hematoma Intimal flap Abnormal contour Requires TEE and expertise!

Valvular dysfunction or septal rupture

Requires expertise beyond our scope

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Clinical Applications of FOCUS

Cardiac arrest -True PEA -Pseudo-PEA PEA ACLS (5H5T) -C.A.U.S.E. protocol -F.E.E.R. protocol

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Clinical Applications of FOCUS

Hypotension/Shock -Cardiogenic shock -Obstructive shock Pacemaker placement IVC screening R.U.S.H. protocol

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Clinical Applications of FOCUS

Dyspnea/Shortness of Breath -Class I indication Global cardiac systolic function Pulmonary edema Pericardial/pleural effusion Valvular heart disease Pulmonary origin -B.L.U.E. protocol
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Clinical Applications of FOCUS

Chest pain - Class I indication Pericardail/Pleural effusion An aortic root greater than 4 cm is suggestive of type A dissection - even a negative comprehensive transthoracic echocardiogram does not rule out aortic dissection Reginal wall motion abnormal
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Endocarditis

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Vegetations

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TTE vs TEE

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Aortic root dissection

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Aortic arch dissection

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Algorithm of FEER

Critical Care Medicine, May 2007; 35(5) Suppl:S150-S161

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Thanks to~~

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Special thanks to~~

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http://vimeo.com/hqmeded/videos
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Thanks for your attention !!

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