Echocardiography in the

Emergency Room/ CCU/

ICU

THANGERVELU ANNAMALAY

ASSISTANT MEDICAL OFFICER U32

MEDICAL DEPARTMENT

HOSPITAL TAIPING, PERAK.

THANGERVELU ANNAMALAYTHANGERVELU ANNAMALAY

ASSISTANT MEDICAL OFFICER U32ASSISTANT MEDICAL OFFICER U32

MEDICAL DEPARTMENTMEDICAL DEPARTMENT

HOSPITAL TAIPING, PERAK.HOSPITAL TAIPING, PERAK.

EMERGENCY EMERGENCY ECHOCARDIOGRAPHYECHOCARDIOGRAPHY

EMERGENCY EMERGENCY

ECHOCARDIOGRAPHYECHOCARDIOGRAPHY

�� When echocardiography becomes important ?When echocardiography becomes important ?

Diagnostic tools in ER/ CCU/ ICU Diagnostic tools in ER/ CCU/ ICU

-- Chest pain Chest pain No ECG changesNo ECG changes

ECG changesECG changes

-- Shortness of breathShortness of breath

-- Syncopal attackSyncopal attack

-- Chest traumaChest trauma

-- Haemodynamically unstable conditions (ICU)Haemodynamically unstable conditions (ICU)

-- Cardiac murmur Cardiac murmur

1. CHEST PAIN1. CHEST PAIN

�� No ECG changes (majority of pts in ER with No ECG changes (majority of pts in ER with

chest pain show no ECG changes). chest pain show no ECG changes).

�� 2D2D-- EchocardiographyEchocardiography-- detect RWAM. detect RWAM.

Therefore early diagnosis possible and treatment Therefore early diagnosis possible and treatment

can be commencedcan be commenced

--Case 1&2Case 1&2-- Mr. X/ 56yrs old c/o Chest painMr. X/ 56yrs old c/o Chest pain

-- ECG normalECG normal

2D echo2D echo-- RWAMRWAM-- anterioranterior-- septalseptal

inferoinfero-- lateral/ PW lateral/ PW

CHEST PAINCHEST PAIN

�� ECG changesECG changes-- ST elevation/ ST elevation/ arrhythamiaarrhythamia

∆∆ ∆∆ i. AMIi. AMI

ii. ii. PericarditisPericarditis

iii. HOCMiii. HOCM

iv. AS/ PSiv. AS/ PS

v. Aortic aneurysm/ dissectionv. Aortic aneurysm/ dissection

vi. AMI with LBBBvi. AMI with LBBB

CASE 3CASE 3

�� Mr. Y/ 60yrs old c/o Chest painMr. Y/ 60yrs old c/o Chest pain

--ECG changesECG changes-- ST elevation V1ST elevation V1--V6V6

--BP 90/60, Pulse 130, SaOBP 90/60, Pulse 130, SaO2 2 -- 70%70%

∆∆ Extensive AMIExtensive AMI

--2D echo2D echo-- ShowsShows-- VentricalVentrical SeptalSeptal

RuptureRupture

2. SHORTNESS OF BREATH2. SHORTNESS OF BREATH

�� Chest XChest X--ray ray -- CardiomegalyCardiomegaly/ Globular heart/ but / Globular heart/ but unable to distinguish murmur unable to distinguish murmur -- require emergency require emergency echocardiography echocardiography

�� To rule outTo rule out

i. CCF/ DCMi. CCF/ DCM

ii. Cardiac tamponade/ Pericardial effusion/ii. Cardiac tamponade/ Pericardial effusion/

Pleural effusionPleural effusion

iii. iii. ValvularValvular heart disease heart disease -- CRHDCRHD

MS/ PS/ MR/ AR/ TR MS/ PS/ MR/ AR/ TR

iv. CHDiv. CHD

vi. Mural thrombus/ Pulmonary embolismvi. Mural thrombus/ Pulmonary embolism

CASE 4(a)CASE 4(a)

��Mrs. A/ 60yrs oldMrs. A/ 60yrs old-- ER/ ICUER/ ICU

c/o Shortness of breathc/o Shortness of breath

BP 90/50, Pulse 130 beats/minBP 90/50, Pulse 130 beats/min

XX--ray shows globular heartray shows globular heart

CASE 4(b)CASE 4(b)

��3yrs old boy3yrs old boy

Shortness of breath/ CyanoticShortness of breath/ Cyanotic

XX--ray/ Globular heartray/ Globular heart

Haemodynamically unstableHaemodynamically unstable

SaOSaO2 2 -- 70%70%

CASE 5(a)CASE 5(a)

�� Mr. R 53yrs old (ER/CCU)Mr. R 53yrs old (ER/CCU)

c/oc/o-- Shortness of breathShortness of breath

Heart rateHeart rate--130bpm130bpm

BpBp-- 100/70mmhg100/70mmhg

SaOSaO22-- 80%80%

ECGECG-- RBBB RBBB

Case 5(b)Case 5(b)

�� 63yrs old female63yrs old female

C/O C/O –– Shortness of breathShortness of breath

B/P B/P –– 90/6090/60

Heart rate Heart rate –– 120 beats/min120 beats/min

SaOSaO2 2 –– 70%70%

ECG ECG -- RBBBRBBB

3. SYNCOPAL ATTACK3. SYNCOPAL ATTACK

�� To rule outTo rule out

i. HOCM/ AS/ PSi. HOCM/ AS/ PS

ii. MVPii. MVP

iii. Intra cardiac mass/ Vegetation/ iii. Intra cardiac mass/ Vegetation/ MyxomaMyxoma

iv. Pulmonary Embolismiv. Pulmonary Embolism

v. Pulmonary Hypertensionv. Pulmonary Hypertension

vi. MSvi. MS

�� Mr. Q Mr. Q -- 20yrs old20yrs old

Presented in ER/ ICU Presented in ER/ ICU ––

Shortness of BreathShortness of Breath

Auscultation Auscultation –– PSM PSM

BP 120/80mmhgBP 120/80mmhg

Pulse 80b/m Pulse 80b/m

Temp. 39Temp. 39°°CC

ECG ECG -- RBBBRBBB

CASE 6CASE 6

4. CHEST TRAUMA4. CHEST TRAUMA

�� MVA/ fall/ AssaultMVA/ fall/ Assault

--Haemodynamically unstableHaemodynamically unstable

--Restless/ ConfusedRestless/ Confused

--Drop in oxygen saturation Drop in oxygen saturation

--Need emergency echocardiographyNeed emergency echocardiography

--To rule outTo rule out-- cardiac tamponade/ pericardial cardiac tamponade/ pericardial

effusion/ cardiac contusion effusion/ cardiac contusion

5. EMERGENCY ECHO in ICU5. EMERGENCY ECHO in ICU

ECHOCARDIOGRAPHY a POPULAR ECHOCARDIOGRAPHY a POPULAR

TOOLTOOLHAEMODYNAMICALLY UNSTABLE CONDITIONS/ HAEMODYNAMICALLY UNSTABLE CONDITIONS/

CARDIAC MURMUR CARDIAC MURMUR

�� Why?Why?i. Urgent diagnostic evaluation leads toi. Urgent diagnostic evaluation leads to

--appropriate intervention appropriate intervention

--improve the course of diseaseimprove the course of disease

--chance of survivalchance of survival

ii. Limit to diagnostic options due to the clinicalii. Limit to diagnostic options due to the clinical

condition and medical environment wherecondition and medical environment where

transportation of patients involves major effortstransportation of patients involves major efforts

and risk.and risk.

iii. iii. High quality imagingHigh quality imaging

iv. iv. NonNon--invasive invasive

vi. vi. Immediate onImmediate on--line image analysisline image analysis

vii. vii. Extensive yield of data (structural, Extensive yield of data (structural, functional functional

& haemodynamic information)& haemodynamic information)

ICU PatientICU Patient

Statistics CCU/ ICU & ERStatistics CCU/ ICU & ER

885885728728490490262262ICU ReferralICU Referral

148148141141136136131131Non Cardiac Non Cardiac AetiologyAetiology

8787188188130130128128NSTEMI & Cardiac NSTEMI & Cardiac

ArrhythmiaArrhythmia

317317209209212212258258Cardiac InfarctCardiac Infarct

20082008200720072006200620052005Conditions Conditions

YearsYears

Emergency Echo in H. Emergency Echo in H. TaipingTaiping

�� Total number Total number

�� 5906 patients5906 patients

�� Required Emergency EchoRequired Emergency Echo

�� 1020 patients1020 patients

�� Percentage Percentage -- 16%16%

CONCLUSIONCONCLUSION

�� Echocardiography study is important and usefulEchocardiography study is important and useful

�� Why?Why?

i. Immediate data direct management i. Immediate data direct management

strategies.strategies.

ii. ii. -- ∆∆∆∆ critical valve disease, critical valve disease, intracardiacintracardiac shunt, shunt,

cardiomyopathycardiomyopathy and tamponade.and tamponade.

So, all of these can easily be diagnosed with So, all of these can easily be diagnosed with

echocardiography and establish a foundation echocardiography and establish a foundation

for initial management. for initial management.

WISHING YOU WISHING YOU -- IN YOUR BUSY IN YOUR BUSY

LIFESTYLE SOME TIME FOR LIFESTYLE SOME TIME FOR

RELAXATIONRELAXATION

& REFLECTION ...... TO HAVE A & REFLECTION ...... TO HAVE A

HAPPY HEART.. KEEP YOUR HEART HAPPY HEART.. KEEP YOUR HEART

SMILING ALWAYS :SMILING ALWAYS :--))

WITH THE BLISS OF REAL LOVEWITH THE BLISS OF REAL LOVE

Special Thanks to :Special Thanks to :Special Thanks to :Special Thanks to :Special Thanks to :Special Thanks to :Special Thanks to :Special Thanks to :--------

�� Dr. Dr. LetchumanLetchuman s/os/o RamanathanRamanathan

Consultant Physician, Consultant Physician,

Head of Medical Department, H. Head of Medical Department, H. TaipingTaiping..

�� Dr. Dr. RamanathanRamanathan s/os/o ManickamManickam

Consultant Physician.Consultant Physician.

�� Dr. Dr. UmadeviUmadevi A. A. MuthukumaruMuthukumaru

Respiratory Physician H. Respiratory Physician H. TaipingTaiping..

MANY BLESSINGS COME

YOUR WAY TODAY:

MAY YOU ALWAYS HAVE

LOVE TO SHARE

HEALTH TO SPARE

AND FRIENDS THAT CARE

THANK YOU.THANK YOU.