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Feature
Advanced Hemodynamic and Cardiopulmonary Ultrasound for Critically Ill Patients in the Emergency Department
Chest radiography is known to have variable test characteristics for the detection of pneumonia. Consolidation may not be detected in profoundly immunocompromised or dehydrated patients. Additionally, in critically ill patients, it is often challenging to obtain a posteroanterior and lateral chest X-ray, given the patient’s hemodynamic status and stability for transport, and a single portable anteroposterior film will often miss retrocardiac infiltrates. In both of these clinical settings, POCUS can provide a rapid diagnosis, expediting the care of these septic patients.
In the presence of a dense consolidation, there may be hepatization of the lung parenchyma ( Figure 4b ). Additionally, hyperechoic air bronchograms are often visualized. Pneumonia is often associated with pleural effusion and localized B-lines. Using lung ultrasound, rapid bedside detection of these pulmonary findings in clinical presentations suggestive of pneumonia can accelerate appropriate antibiotic and respiratory supportive treatment.
Left Ventricular Systolic Assessment
Critically ill patients commonly present with a mixed shock picture, and it is rare for a patient to have solely cardiogenic shock, hemorrhagic shock, etc. Rather, a patient who presents in septic shock may have an underlying cardiomyopathy for which she or he is being treated with a beta-blocker.
Cardiomyopathy associated with sepsis is common 18 and, at least in the case of diastolic dysfunction, it is underdiagnosed and associated with a higher mortality rate. 19 It is therefore essential that the EP evaluate left ventricular (LV) systolic function rapidly and reliably—particularly in critically ill patients whose disease process may be undifferentiated and whose hemodynamic status is unclear. 20-22 Bedside echocardiography by the EP is invaluable in identifying the LV contribution to the hemodynamic profile and tailoring resuscitation to optimize patient outcomes.
Although gross visual assessment is the most widely used method by which EPs estimate LV systolic function, this strategy is subjective, operator-dependent, and requires at least two quality views to understand the heart’s three-dimensional movement. However, when faced with a rapid diagnostic dilemma, a global visual estimate of the overall contractility (hyperdynamic, normal, depressed, severely depressed) may be more useful than estimating the ejection fraction (EF), especially when the patient’s baseline EF is unknown.
Regional Wall-Motion Abnormalities
Regional wall-motion abnormalities can be evaluated by considering and correlating the coronary artery distributions with the electrocardiographic findings and the clinical scenario ( Figure 5 ).
Figure 5.
Each region can be assessed for degree of movement of the myocardium toward the center of the LV during systole, or abnormal thickening of the ventricular walls. Although the American Heart Association uses a 17-segment model for this assessment, this level of detail may not be necessary for a POCUS evaluation. 23
Simpson’s Rule
Although no one parameter can quantitatively assess LV function, the EF is the one most commonly used. The Simpson’s Rule or the “method of disks” estimates EF by changes in calculated ventricular volumes. The endocardial border is outlined in end-diastole and end-systole (ES) in both the apical four- (AP4) and two-chamber views. The cardiac package on the ultrasound system can divide the selected area into a series of disks, calculate the volume of each disk, and then add these figures to estimate the ventricular volume ( Figure 6a ). Limitations of this study include potentially difficult visualization of the endocardial border, and the length of time to conduct this study.
