Brought to you by: Maninder Singh, Priya Ghelani and Brian Gilberti
Cardiac Ultrasound – Dr. Martin
-5 E’s of Cardiac POCUS: Entrance (IVC), Exit (Outflow Tract), Equality (RV:LV), EF, Effusion
-If you have a poor view on subxiphoid approach, try having the patient inhale
-If you have a poor view on PSL, PSS, or Apical 4 approach, try having the patient exhale
-D sign: septal bowing into LV on parasternal short http://emoryeus.blogspot
– How to do an US-guided pericardiocentesis in the setting of tamponade (diastolic RV collapse): https://www.aliem.com/2013/08/
Sim Case 1: Posterior STEMI
-Posterior STEMIs are the most commonly missed, only 0.5 mm elevation is required to make the diagnosis https://lifeinthefas
-Consider posterior MI if ST depressions in lateral leads with large R waves and upright T’s
-Use the “PAILS” mnemonic to determine where you should be looking for reciprocal elevations or depressions on EKGs.
-Get repeat EKGs if the patient does not yet meet STEMI criteria but seems to clinically seems to be having an ACS
-Keep EtCO2>20 during compressions: https://lifeinth
-Early defibrillation saves lives. If there is a risk for decompensation, place pads on patients early.
Sim Case 2: Blunt Trauma
-ACLS may not be the answer for blunt traumatic arrest.
-Rule out PTX, localize source of bleeding (chest tubes, FAST, ED thoracotomy) and proper resuscitation (MTP, Filling the tank, fixing impeded venous return, and making sure the heart can accept blood) is key. Further reading: http://blog.ercast.org/trauma
-Legally, parents of children (<18 years old) cannot interfere with interventions that are expected to otherwise improve life or limb-threatening injuries (e.g. MTP in Jehovah’s Witness patients)
-If your patient is still hypoxic with a supraglottic device, reassess your need for a definitive airway
-Keep in mind occult PTXs can convert to tension PTX when patient placed on PPV and consider chest tubes early, if unsure.
Further Discussion Points
-US example of D sign on page 3: https://criticalcarethoughtsdotcom.files.wordpress.com/2014/05/rv-bedside-echo.pdf
– POCUS in cardiac arrest (July EMRAP paper chase, Gaspari et al): 51% of those in PEA/asystole with cardiac activity at initial US achieved ROSC (converse is not true) http://www.jwatch.org/
-Posterior MI: Good case on ecgweekly
–Lead placement reviewed
–STEMI meds reviewed in July’s EMRAP
-LMA or bagging superior or equal to ETT in codes, likely due to pause in compressions typically taken to intubate
-Indications for ED Thoracotomy (EAST recommendations pg 12)