Transthoracic Echocardiography

Echocardiography brought to the bedside of an ED patient is noninvasive, portable, and provides immediate bedside images. Although the techniques of echocardiography are beyond the scope of this chapter, the viewing windows are easy to identify and to access. 21 The subcostal view, at the left intercostal margin at its junction with the xiphoid process, yields information regarding presence of fluid, wall motion, and chamber size. The parasternal view, at the left upper intercostal spaces, gives images of the aorta, cardiac chambers, and heart valves.22

Emergency bedside echocardiography is usually performed to detect two conditions: pericardial fluid (in the setting of possible pericardial tamponade) and cardiac wall motion (in the setting of cardiac arrest with maintained electrical activity—pulseless electrical activity or PEA). In both of these settings, the interpretation provided by emergency physician bedside echocardiography has been accurate for clinical decision making. 2324 Both conditions can be evaluated by performing a limited examination using the subcostal view. A pericardial effusion is identified as fluid following the contour of the heart with the surrounding hyperechoic image of the pericardium. The findings of fluid, hyperdynamic heart, and diastolic collapse of the right atrium and ventricle suggest tamponade. 22 In a pulseless patient with electrical activity on the monitor, echocardiography may accurately identify treatable causes. 24

Other indications for emergency bedside echocardiography include hypotension of unknown cause, suspected cardiac trauma (blunt or penetrating), and suspected ischemic heart disease. Hyperdynamic wall motion without pericardial fluid suggests hypovolemia. Pericardial fluid suggests cardiac injury. Tension pneumothorax can be suggested by difficulty in visualizing the heart due to an air interface.

Evaluation of patients with possible ischemic chest pain requires a more thorough echocardiographic examination than is usually possible using the equipment and training available to most emergency physicians. Additional training and specific equipment are required to accurately assess cardiac wall motion, cardiac chamber size, and valve function. If the appropriate equipment and physician (usually a cardiologist) are available, though, echocardiography can be very useful in evaluating patients with chest pain.25 Early echocardiography in the emergency department is more sensitive than an electrocardiogram (ECG) (91 percent versus 40 percent) in predicting acute infarction or revascularization.25 Echocardiography can identify and assess complications of ischemia: pump failure, mitral valve insufficiency, and pericardial effusion. Along with the medical history, ECG, and serologic markers, echocardiography may aid in the triage process of patients with chest pain. 25

Other diagnoses that can be made with echocardiography include acute PE, aortic dissection, and cardiac contusion; however, advanced training is necessary to diagnose these conditions accurately.22

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