In the parasternal long axis view the normal

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]. In the parasternal long-axis view, the normal circularappear- ance of the left ventricle can become D-shaped as abnormally high right ven- tricular pressures deform the septum out from the right ventricle ( Figure 3.30 ). If a patient has a massive PE and is hemodynamically unstable, there may not be time to obtain tests such as computed tomography scanning or transesophageal echocardiography. Therefore, in the right clinical setting, the detection of a dilated, stiff right ventricle may provide evidence for consideration of lysis [ 3,26 –29]. Figure 3.28 The heart on the left has M-mode waveforms, indicating contractility. The heart on the right has flat M-mode lines, indicating asystole and no contractions. Figure 3.29 This subxiphoid view shows a very enlarged right ventricle – in fact, it is difficult to tell the right from the left ventricle becausetheyareboth the same size. This image was obtained from a patient with a saddle pulmonary emboluswhorequired lysis. Courtesy of Emergency Ultrasound Division, St. Luke’s–Roosevelt Hospital Center, New York, NY. Diagnostic ultrasound 85 Cardiac ultrasound
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Sample clinical protocols Figures 3.31 and 3.32 show protocols for ultrasound use in cardiac arrest and penetrating thoracic injury. Penetrating thoracic trauma Pericardial effusion No pericardial effusion Hypotension or PEA ED thoracotomy or OR Stable vital signs OR Observation, repeat testing or CT scan Figure 3.32 Protocol for ultrasound use in penetrating thoracic injury. Figure 3.30 The parasternal short-axis view in a patient with elevated right ventricular pressure. Note the flattened septum (*), which deforms the normal circular appearance of the left ventricle (LV) into a D-shape. Cardiac contractility Continue efforts Ventricular fibrillation Defibrillation Dilated RV poor contractility PE possible, consider lysis Pericardial effusion Consider pericardiocentesis Cardiac standstill Consider termination of efforts Cardiac arrest, ACLS in progress Figure 3.31 Protocol for ultrasound use in cardiac arrest. 86 Diagnostic ultrasound Cardiac ultrasound
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Literature review Reference Methods Results Notes Blaivas & Fox 2001 [ 24 ] 169 emergency department (ED) patients undergoing ACLS resuscitation, bedside cardiac US during code by emergency physicians (EPs). Cardiac standstill on initial echocardiogram in patients with ongoing CPR had 100% positive predictive value (PPV) for death. Provided data for bedside cardiac US findings indicative of poor outcomes and of when to stop ACLS resuscitation. Plummer et al. 1992 [ 5 ] Penetrating trauma patients randomized to ED US vs. “standard of care” evaluation (cardiac US called in). Diagnosis and disposition expedited in ED US group, also noted survival benefit if patients had ED US. Mortality benefit of ED US in penetrating cardiac injury.
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