This post provides the explanation to the video posted yesterday- click here if you haven't looked at that post yet.
The patient was a 56 year old male who arrived in the ED in PEA cardiac arrest. The video shows a subxiphoid view. The most striking initial observation on echo was the gap between the pericardium and the anterior wall of the RV.
Is this a pericardial effusion? Is this cardiac arrest due to tamponade?
Only looking more closely you can see that there is some RV activity but the LV is completely akinetic. This was the cause of the patients cardiac arrest. So what is is causing the gap between the RV and pericardium? This is due to a pericardial fat pad.
Look again at the gap and you will note that there are echoes within the space, it is brighter than the myocardium and moves together with the RV. Pericardial fat pads are typical seen anterior to the RV.
The video below shows a subxiphoid echo view taken during a PEA cardiac arrest. What's the cause?
You can find the answer here
Do you know what you should be looking for to diagnose cardiac tamponade? The American Society of Echocardiography guideline on imaging in pericardial disease provides a useful summary of the evidence relating to the different signs (page 985 onwards).
For a practical overview of the signs, with example cases, the two videos below from Ultrasound Podcast, will keep you entertained.
In the words of the authors, FAST & RELIABLE is "a comprehensive ultrasound protocol aimed to quickly differentiate between the major causes of hypotension". Some of the components of the protocol may be slightly beyond the skills of a beginner POCUS practitioner. Those skills, e.g.
Sagittal and transverse views of the uterus and adnexae in the suprapubic area , DVT scanning at femoral and popliteal veins, are not unachievable skills.
1. Click here for a pictorial summary of the FAST & RELIABLE protocol.
2. Diagram from the article: the causes of hypotension and how the FAST & RELIABLE protocol is relevant.
This is an entertaining 3 minute rap from The EMC summarising echo findings of right heart strain like what you might see in pulmonary embolism. "Right heart strain pushed the septum to the left to the left!". Enjoy.
This 100-page introduction by Philips provides a huge amount of detail. It covers the basic views, assessment of structures and measurements. There is also a brief outline integrating echo into resuscitation. The document can be downloaded as a pdf but you will need an internet connection to view the videos. There is also a point-of-care echo pocket card outlining the view and anatomy which can be downloaded separately.
Introduction to transthoracic echocardiography
Point-of-care echo pocket card