Simple Emergency Cardiac Sonography. The chapter on this subject is extensively dealt with in Chapter 19 of Lung Ultrasound in the Critically Ill.
Simple Emergency Cardiac Sonography
Simple Emergency Cardiac Sonography The chapter on this subject is extensively dealt with in Chapter 19 of Lung Ultrasound in the Critically Ill (Springer-Verlag 2016). For avoiding any copyright issue, we deal here with our data, which likely we will never find time to submit (with in addition increasing risks of rejections). Please note that the definition of holistic ultrasound includes the fact that the heart is not the unique target. Many questions are answered by looking at the lung and the veins (the principle of the BLUE-protocol). One example : if one unit not 2) of energy must be spent, we should teach to a physician of critical care to learn the B-line and lung rockets with lung sliding, instead (or before) of the left ventricle assessment. In fact, the detection of a B-profile (diffuse anterior lung rockets with lung sliding in a dyspneic patient) shows high possibility of hemodynamic pulmonary edema; the absence of a B-profile shows evidence of the absence of hemodynamic pulmonary edema. In this acceptation, quite all chapters of the book deal with clinical concerns where, usually, the physician applies echocardiography : acute respiratory failure, acute circulatory failure, even cardiac arrest. What is Simple Emergency Cardiac Sonography ? 1) It deals with the heart, definitely a major (but not unique) vital organ. 2) This heart is visited in the emergency, which means no time to request the usual specialist (the cardiologist, in addition not always accustomed to deal with emergency settings). 3) Neither Echo (usual term for the heart) nor Ultrasound (traditional term for the abdomen), we used the neutral term Sonography. 4) Since the heart is a very complicate organ, since the first-line physician is not an expert, since the patient is critically ill, the only way to make it realistic and efficient is to use simplicity – as far as the security of the patient is not compromised, this is the target of CEURF. We use a single, microconvex probe, not a cardiac probe, because we can assess the whole body, including the heart using this probe. We do not spend too much time for acquiring exact echocardiographic view, time-demanding, often missing when poor windows, for the same reason that one can recognize any familiar person even if not strictly face or profile. We use a simple machine, without harmonics nor compound, i.e., no complication, and a machine able to assess all sites (of critical importance in cardiac arrest – the SESAME-protocol). We use the subcostal route mainly, an if not available, we try our best (in a supine patient) at the anterior chest wall. Our first target : pericardium Is not really the heart but the pericardium, a structure distinct from the heart, in the spirit of CEURF. To detect a pericardial effusion in a critically ill patient is a major step. If the effusion is large, if the right ventricle is small, the possibility of a tamponade is quite certain. Very importantly, our microconvex probe is able to see both the pericardial effusion and the needle which will be promptly inserted (unlike cardiac probes usually). This is another face of holistic ultrasound.
Our second target : right ventricle We pay high attention at the volume of the right ventricle. 1) in the case of a pericardial effusion (see above). 2) in a shocked patient. An enlarged right ventricle can be seen in pulmonary embolism, usually, also in rare causes (right ventricle infarction, all cases of pulmonary hypertension). When the right ventricle is seen not dilated, the FALLS-protocol is resumed.
Our next target : ??? The left ventricle contractility is very accessible to learning. It does not feature in the CEURF protocols, just because the lung shows a dichotomic answer (read above). Each time there is a B-profile with a clinical suspicion of non hemodynamic interstitial syndrome (pneumonia/ARDS, chronic lung disease), the LV contractility is, of course, analyzed. Yet diastolic function and other subtleties are not dealt with in our book, we just here, when clinically indicated, ask for a specialist (this is the DIAFORA approach – Doppler intermittently asked from outside in rare applications). The LV hypertrophy cannot be treated on admission, we treat the consequence (pulmonary edema, e.g.). Although easy, it is not in our protocols. Similarly, the mitral, aortic valves are not fixed on admission (apart really exceptional cases where a nocturnal repairment is decided), the question is again, is the left heart or left valve responsible for the disease ? Anyway, if a window is accessible, it is often possible to detect an anomaly with the simple vision of the valve. Dilated cardiac diseases : same approach, we see first if they are really responsible for the disorder (pulmonary edema, yes or not). Endocarditis : although visible in most cases using transthoracic approach, it is not frequent, so we advise to use the unit of energy, first at the lung, and see all these cardiac items, just after, with all the necessary time. The rest, congenital heart disorders and countless issues that are comprehensively dealt with in authoritative textbooks, follows the same thought process.
Aside notes In the BLUE-protocol, the heart is not included. It is associated, if needed, once the BLUE-protocol over, for making an even superior test (reminder, in the BLUE-protocol, and without cardiac analysis, the specificity for pulmonary embolism is 99%). In plethoric patients, in patients without a cardiac window, even in patients without cardiac window and without possibility of trans-esophageal echocardiography, lung and venous ultrasound can provide critical information. Note that TEE is not possible in most instances : - when the physician has not been trained - when the patient has local contra-indication - and in most settings in the world, for economic reasons. The SLAM, a section of CEURF (section for the limitation of acronyms in medicine) has decided not to give any acronym to this approach (cf FATE, FEER, FEEL, RACE and others).
