Introduction Slide 1 of 623456 Focused Cardiac Ultrasound (FOCUS) or Emergency Echo Pathology and the 5Es E ... E ... E ... E ... E Echo is an indispensable tool when a patient is sick Hypotension Tachycardia Shortness of breath Chest pain Syncope Penetrating trauma Continue NarrationThis lecture builds on the basic cardiac lecture to talk about pathology. Echo is an indispensable tool in the acute care setting, particularly when a patient is sick and you don't know exactly why. This picture shows an unfortunate gentleman you may recognize, Steve Irwin, he suffered a penetrating injury to his heart from a sting ray and died from what was likely a pericardial tamponade. So that's the first E we'll talk about, which is pericardial effusion, and there are several other E's we've worked out as pathology that can be easily and reproducibly found by people who take the time to learn basic focused cardiac ultrasound or focused cardiac echo. If someone comes in with any of these complaints that could be something serious, you're not sure what's causing it: low blood pressure, hypotension, tachycardia, shortness of breath, chest pain, syncope/passing out, or penetrating trauma, echo is a tool you really need to know how to use. Case - 42 y.o. male 42 y.o. male was ‘walking through metal detector’ and collapsed Arrives awake but in some distress, diaphoretic, complaining of shortness of breath HR 126 Blood pressure 105/70 O2 % saturation 94% on 2L EKG shows sinus tachycardia without ST elevation Differential? Plan? Continue NarrationSo I'd like to start with a case, and this was a patient I saw several years ago, brought in by EMS. He was a 42 year old African American gentleman and walking through a metal detector and he collapsed. EMS thought for some reason the metal detector had done him in. When he showed up, he did look somewhat distressed - he was sweating, diaphoretic, and complaining primarily of shortness of breath. He denied real chest pain; he was tachycardic and his blood pressure was a bit borderline. His oxygen saturation was on the lower side. We did an initial EKG showed sinus tachycardia without ST elevation. What’s your differential here and what would you do? I was thinking for sure this guy was a large or massive pulmonary embolism with the collapse, the tachycardia, the shortness of breath. I went straight to ultrasound to see if I could see if the right ventricle was enlarged or if there was other pathology and this is what we saw. Case Continue NarrationSo this is a parasternal long axis view which we've gone over in the basic lecture, and it’s a little fuzzy- it's real world. It’s a phased array probe. You can see the heart beating. If you look around the heart there's a homogenous grey area with a very small black fluid filled area, and this is essentially pericardial effusion with clot. The other thing he has is dilation of the thoracic aorta, which is the aorta coming out of the left ventricle. This combination of these two things is pathognomic for a type A aortic dissection. E is For Effusion and Exit Type A ascending thoracic aortic dissection Continue NarrationWe'll talk about this in the talk itself, but this diagram shows that clot in the pericardium the non clotted effusion and the dilated thoracic root. You can't actually see the flap in this case, but he had dissected back to the pericardium, and was about to code essentially from the fluid and clot around the heart. We were able to get cardiothorasic surgery to the bedside right away and got him to the operating room within about a half an hour. He actually survived and did well. Without ultrasound we may have figured this out at some point but it might have taken longer, and it’s very possible that he have died before we got the diagnosis.Focused Cardiac Ultrasound (FOCUS) - Pathology We have developed the “5Es” of Emergency Echo Pathology that is relevant and reproducible E ffusion E jection E quality E xit E ntrance Acad Emerg Med. 2015 May;22(5):583-93. doi: 10.1111/acem.12652 Continue NarrationSo as mentioned here at Yale, we have developed what are called the 5 Es of emergency echo or focused cardiac ultrasound. This is what we have found over time to be pathology that is relevant and also reproducible in the sense that we can reliably find it even with limited training. It certainly benefits to have more training, and we'll talk about some advanced applications in another lecture, but I do believe that with basic cardiac ultrasound training and some experience, you can detect these 5 pathologies and they are incredibly important to taking care of patients in the acute setting. These five Es are the Effusion; Ejection, or how is the squeeze of the left ventricle; Equality is the right ventricle as big or bigger than the left ventricle indicating possible pulmonary embolism; Exit, or thoracic aortic root that we looked at in this last case is it dilated, which can go along with thoracic dissection, and finally Entrance, or inferior vena cava which can give us a sense of fluid status.Parasternal long axis – imaging conventions See: Moore C, “Current Issues with Emergency Cardiac Ultrasound Probe and Image Conventions” Acad Emerg Med 2008; 15:278–284 Continue NarrationWe talked about this in the basic lecture, but just want to reiterate that we are using an imaging convention that is consistent with other radiology imaging conventions, or point-of-care ultrasound conventions, and for the parasternal view, we'll keep the indictor to the patients right shoulder so this will be reversed from what we might see in some emergency medicine texts or cardiology texts where the base of the heart is on the right side of the screen. You can get that image if you want, it'll be the same anatomy by either turning the probe around with the indicator kept on the left or reversing the indictor and reversing the probe. There is an article on this that talks about this cited above. Emergency Echo 5 Es --- Table of Contents --- Lesson NameMinutes id Introduction7 171 E is for Effusion6 172 E is for Ejection7 173 E is for Equality7 174 E is for Exit7 175 E is for Entrance5 176 Summary1 177
