Echo & Resus


53 year old father of three brought in EMS status post syncopal episode, followed by bradycardia requiring pacing, and ultimately altered mental status requiring intubation. On arrival, there was no palpable pulse, and no pulse ox reading. The team leader considered chest compressions and re-intubation. Immediately prior to these interventions, CUS revealed: 

What would you do next?

What to Know
  1. List the indications, contraindications and limitations of FOCUS.
  2. Identify relevant sonographic anatomy including cardiac chambers, valves, and pericardium
  3. Perform the required subcostal, parasternal, and apical views as well as the required views for the thoracic, trauma, aorta, and deep venous CUS exams.
  4. Recognize the relevant focused findings to detect cardiac activity and pericardial effusions with or without tamponade.
  5. Estimate qualitative left ventricular function as well as central venous pressure through visualization of the inferior vena cava. 
  6. Identify a dilated aortic root and descending thoracic aorta. 
  7. Explain pitfalls and how to utilize both FOCUS and the Rapid US in sHock (RUSH) exam to guide resuscitation in critically ill patients

What to Read: Introduction to Bedside Ultrasound
Free iBook download Vol 1 and Vol 2
Chapter 2: Basic Cardiac
Chapter 16: Echocardiographic Assessment of Cardiac Output and Ejection Fraction
Chapter 17: Right Heart
Chapter 18: Diastology
Chapter 19: TEE
Chapter 12: Fluid Responsiveness
Where to Learn More

US Podcasts - Resus
Key Articles
  1. Consensus. ACEP Emergency ultrasound guidelines. Ann Emerg Med. 2009;53(4):550–570.
  2. Nazerian P, Vanni S, Zanobetti M, et al. Diagnostic accuracy of emergency Doppler echocardiography for identification of acute left ventricular heart failure in patients with acute dyspnea: comparison with Boston criteria and N-terminal prohormone brain natriuretic peptide. Acad Emerg Med. 2010;17(1):18-26.
  3. Mantuani D, Nagdev A. Three-view bedside ultrasound to differentiate acute decompensated heart failure from chronic obstructive pulmonary disease. Am J Emerg Med. 2013:2012–2014.
  4. Nazerian P, Vanni S, Volpicelli G, et al. Accuracy of Point-of-Care Multiorgan Ultrasonography for the Diagnosis of Pulmonary Embolism. Chest. 2014;145(5):950-7.
  5. Nagdev AD, Merchant RC, Tirado-Gonzalez A, Sisson CA, Murphy MC. Emergency Department Bedside Ultrasonographic Measurement of the Caval Index for Noninvasive Determination of Low Central Venous Pressure. YMEM. 2009:1–6.
  6. Blehar DJ, Dickman E, Gaspari R. Identification of congestive heart failure via respiratory variation of inferior vena cava diameter. Am J Emerg Med. 2009;27(1):71-75.
  7. Jones AE, Tayal VS, Sullivan DM, Kline JA. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med. 2004;32(8):1703–1708
  8. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am. 2010;28(1):29–56, vii.

Great Case
Shortness of Breath by Bobby Needleman

Test Yourself
Advanced Echo Self Assessment Quiz

Case Follow Up

Amplitude and rate of pacemaker increased until capture obtained. Dopamine started. 

Endotracheal tube not removed. Pulse Ox at 100% as perfusion returned. EKG with complete heart block. Patient transferred immediately to cath lab for stenting of 100% RCA Occlusion. Walked out of hospital with family 5 days later.