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Jul 15, 2009 - Abstract. Context: Focused echocardiography evaluation in life support (FEEL) for emergency and critical care medicine is an innovative ...
European Journal of Trauma and Emergency Surgery

Focus on Ultrasound in Trauma and Emergency Surgery

Focused Echocardiography in Life Support: The Subcostal Window What the Surgeon Should Know for Critical Care Applications Raoul Breitkreutz1, Felix Walcher2, Hendrik Ilper1, Florian H. Seeger3, Susanna Price4, Gabriele Via5, Holger Steiger6

Abstract Context: Focused echocardiography evaluation in life support (FEEL) for emergency and critical care medicine is an innovative approach to introducing limited-in-scope echocardiography in a timely fashion into periresuscitation care. FEEL is an advanced life support-conformed concept and a simple procedure that can be readily used in shock room or pre-hospital scenarios as an extension of focused abdominal sonography for trauma (FAST). The subcostal window plays a pivotal role in this context, because it can easily be applied in the supine position, and is usually better than other windows in patients with mechanical ventilation or during resuscitation maneuvers. Most information can be obtained at a glance. Aim: As the FAST exam was not developed for implementation in resuscitation or cardiac arrest procedures, here we describe an accurate and easy method that allows non-cardiologists to add FEEL to the FAST exam. As a result, it conforms to actual resuscitation guidelines. To perform the FEEL procedure and the subcostal window, a specific training seems to be mandatory. The aim of this paper is to set special emphasis on the use of the subcostal window. Key Words Time Æ Training Æ Periresuscitation care Æ Nonspecialist Æ Focused Æ Echocardiography in life support

Eur J Trauma Emerg Surg 2009;35:347–56 DOI 10.1007/s00068-009-9093-1

Introduction In emergency and critical care medicine, ultrasound can be employed as a simple diagnostic tool at the patients’ bedside by utilizing modern mobile technology. This approach has resulted from a shift in paradigm in the use of ultrasound: non-imaging specialists can safely and effectively apply ultrasound in the clinical context in a focused manner, rather than as a time-consuming comprehensive exam. In this way, surgeon-performed focused abdominal sonography for trauma (FAST) has now become an established procedure [1, 2]. Non-cardiologists such as critical care physicians (CCP) and emergency physicians (EP) can apply transthoracic echocardiography (TTE) through an analogous approach [3]. Undifferentiated hypotension is a leading cause of adverse outcome in hospitalized patients. Jones et al. [4] showed that emergency physicians (EPs) can reduce the number of viable diagnoses by applying an ultrasound exam to patients with undifferentiated hypotension immediately upon their arrival at an emergency department (ED). It was also demonstrated that cardiogenic/noncardiogenic causes of shock could be discriminated by applying TTE in intensive care

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Clinics of Anesthesiology, Intensive Care Medicine and Pain Therapy, Hospital of the Johann Wolfgang Goethe-University, Frankfurt am Main, Germany, 2 Trauma Surgery, Hospital of the Johann Wolfgang GoetheUniversity, Frankfurt am Main, Germany, 3 Department of Cardiology, Hospital of the Johann Wolfgang Goethe-University, Frankfurt am Main, Germany, 4 Adult Intensive Care Unit, Royal Brompton Hospital, London, UK, 5 1st Department of Anesthesia and Intensive, Care, Fondazione IRCCS Policlinico San Matteo, P.zzale Golgi 2, 27100, Pavia, Italy, 6 Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany. Received: May 22, 2009; revision accepted: June 16, 2009; Published Online: July 15, 2009

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units (ICU), leading to consistent therapeutical changes [3–5]. The FAST procedure is a surgeon-performed ultrasound assessment. In detail, six body positions are included in the FAST exam, including a cardiac view. Pleural views were also included in an extended FAST exam (E-FAST). TTE was also suggested for minimally trained operators [6–9]. When performing the FAST exam in critical scenarios, cardiac tamponade should also be addressed [2, 3]. However, in the context of resuscitation, this must be done in a very short time frame, and FAST was not developed for use within seconds.

Nonspecialized Echocardiography for Periresuscitation Periresuscitation care scenarios can occur in the ED/ shock room, medical outreach emergency team, ICU, or pre-hospital. Focused TTE can serve to detect important pathologies [3, 10, 11], just as the ECG detects disturbances in cardiac rhythm. Several guidelines now request focused imaging assessment as an early diagnostic step [11, 12]. As an important example, the latest guidelines of the European Society of Cardiology recommend echocardiography in cases of suspected pulmonary embolism when the patient is too unstable or a CT scan is not available immediately [11]. Focused TTE during resuscitation and periresuscitation can identify several underlying causes (tamponade, myocardial insufficiency in pulmonary embolism or acute myocardial infarction, hypovolemia, and tension pneumothorax) when other techniques fail to provide answers [3] or are more time consuming. The aim of this paper is to explain the use of the subcostal window and how to perform the FEEL exam.

The Subcostal Window In a comprehensive cardiological TTE, parasternal and apical windows in the left lateral position are usually the preferred windows for qualitative and quantitative assessment. The subcostal window is used, if at all, as an optional assessment. However, in emergency scenarios and in ventilated patients in an ICU, the patients normally lie in the supine position. The subcostal window can be achieved more easily in this position than in the parasternal or apical approaches. Furthermore, assessment of the inferior vena cava yields information of paramount importance in critically ill patients [13, 14].

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In detail, the use of the subcostal approach will allow the heart to be visualized in at least two standard planes (Figures 1, 2). The first one yields a long-axis view, which should depict all four cardiac chambers. As assessment is dynamic in spontaneous breathing or artificial ventilation, the view of the ventricles and atria can vary. Topographically, the subcostal four-chamber view is similar to the apical four-chamber view, although its plane is rotated 90 (the ultrasound scan sector penetrates the heart from below and not from the apex; Figures 1, 2). Atypical (off-axis) views are sometimes obtained from the subcostal window, and not all of the four chambers are correctly visualized. This should not be aimed for, as it potentially leads to inaccurate estimates of anatomical sizes. The second plane of investigation of the subcostal window yields a short axis view. From the four-chamber view, the probe indicator can be rotated and pointed toward the feet (Figures 3, 4), obtaining a view comparable to the short axis one of the parasternal approach. Centered at the midventricular level, it shows the same anatomical structures (right and left ventricles, papillary muscles). A third useful investigation is targeted at the inferior vena cava. From the subcostal four-chamber view, rocking the probe toward the liver allows the right atrium to be centered. A counterclockwise rotation of 70–90 aligns the scan sector parallel to the

Figure 1. Topography of the spatial planes used to orientate TTE views of the heart. Entry sites of the ultrasound beam at the levels of the different TTE windows are indicated by arrowheads. Note that subcostal and apical windows share a common long axis (LAX) plane of investigation (LAX2), which in fact yields a similar fourchamber view. In the same manner, the subcostal and the parasternal windows also share a common short axis (SAX) plane of investigation, which yields a similar midpapillary SAX view.

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Figure 2. illustrating the concept of short axis (SAX) and long axis (LAX1, LAX2) views of the heart using the example of slicing into a banana. LAX views visualize the heart along its major axis; i.e., they retain the structures of the base (B) and the apex (A) in the image. SAX views are perpendicular to LAX views and represent ‘‘slices’’ that can be performed at different points along the long axis.

long axis of the inferior vena, which is visualized along its longitudinal axis, crossing the diaphragm and entering the right atrium (Figure 4). Note the topography and distance of the heart in the scale of the B-mode picture (Figure 5): the heart is usually more than 10 cm from the surface of the thorax, as the ultrasound beam must first penetrate the skin, subcutaneous tissues and the left lobe of the liver (Figure 5). The liver serves as a perfect ‘‘acoustic window’’ to transmit the ultrasound beam to the heart, and clear images are usually obtained (‘‘the liver is your friend’’). When the ultrasound beam crosses the diaphragm a strong echogenic line is obtained. As the pericardial layers (the first cardiac structures to be

encountered) are normally closely attached, they determine this echogenic (bright) outline of the heart. There are two ways to display a subcostal fourchamber view on the screen: orientate the apex to the left (as taught in the FAST protocol) or to the right (as in the cardiological approach, compare Figures 5 and 10a). To maximize the chances of obtaining adequate subcostal views in the emergency setting, one should consider the following practical steps: (1) Make sure that the ultrasound machine is ready to start (with 2-D modality). Use standard settings and a depth of not less than 15 cm.

Figures 3a and 3b. a) Probe application in the subxiphoid region with marker directed toward the left flank for a longaxis view in order to obtain a subcostal four-chamber view. b) 90 clockwise rotation; pointing the marker towards the feet will yield a subcostal short-axis view. This gives exactly the same view as in the parasternal window.

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Figures 4a to 4d. Technique used to obtain a subcostal view of the inferior vena cava (IVC) from the subcostal four-chamber view. By rocking (i.e., angling in the scanning plane) toward the liver (a), the right atrium is centered in the scan sector. A counterclockwise rotation of 70–90 (b), pointing the marker cephalad (c), will obtain alignment with the longitudinal axis of the IVC. The vessel will be visualized crossing the liver and the diaphragm and then entering the right atrium (d).

Figures 5a and 5b. Subcostal window, normal findings. a) Four-chamber view. Note the triangular shape of the right ventricle and the conoid shape (‘‘bullet shape’’) of the left ventricle. All four chambers are clearly identified. LL, left lobe of the liver; IVS, interventricular septum. b) Midpapillary short-axis view (similar to the parasternal short axis). The right ventricle has a crescent shape, while the left ventricle appears with its round shape.

(2) Use either an abdominal probe (convex shaped), a cardiological sector phased-array probe, or a microconvex probe. If possible, set the frequency from 2.5 to no more than 5 MHz. Linear probes or

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other probes with high frequency are unsuitable for investigating structures placed at a depth such as that of the heart in the subcostal approach. (3) If there is enough time to prepare, put patient-

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Figure 6. Proposed integration of FEEL into the ERC 2005 ALS algorithm. In the case of nonshockable rhythms, brief echocardiography according to FEEL can be considered in order to identify treatable conditions. Please note that this is a proposal by the authors only, and had not been confirmed or granted by any resuscitation society by the time of publication.

Proposed integration of focussed echocardiography (FEEL) into advanced life support (ERC 2005) to diagnose treatable causes of CPR

Unresponsive? open airway, airway signs of life?

CPR: 30:2 Defibrillator/Monitor

Assess rhythm

Defibrillation

Shockable?

Non-shockable?

(VF, pVT)

(PEA, Asystole)

1x Defibrillation 2 min. of CPR 30:2

2 min. of CPR 30:2

Consider echocardiography

Performance of “FEEL” e.g. to diagnose pericardial effusion, enlarged right ventricle, hypovolemia, pseudo-PEA. Watch spO2 and exspir. exspir CO2

related data into the ultrasound machine to allow for proper storage and subsequent review. (4) Use your index finger to palpate the xiphoid before you apply the probe onto the patient’s skin. This clinical examination before the start of imaging is very helpful, since the xiphoid can hinder the path of the ultrasound beam to the heart. (5) Place the probe into the epigastric region, approximately 1–2 cm below the xiphoid. Place the probe at a very flat angle to the surface of the patient’s body (less than 10) in order to direct the ultrasound beam upward and slightly to the left (Figure 3). This will align it with the left lobe of the liver and exploit this acoustic window. If reverberation occurs and no cardiac structure can

be identified, this could be caused by interposition of air in the stomach or bowels. Bony artefacts (an enemy of ultrasound because of dorsal shadowing) are rare, but one should also consider the xiphoid or ribs with dorsal shadowing. One major pitfall is holding the probe like a pencil, surrounding its head with the thumb and index finger. This will automatically increase the angle of the probe in relation to the patient’s body surface. On the other hand, one could simply place the probe on the body surface, as if it was completely lying on it, and then press only the tip of the probe gently into the patient’s subcutaneous tissue (Figure 3). If the probe is oriented at an angle of greater than 10 in relation to the body surface, the ultrasound scan

Figure 7. Example of a subcostal four-chamber view in dilated cardiomyopathy (DCM), end of diastole. Note the dilatation of all four chambers in comparison to a normal heart. Assessment by eye of the moving pictures shows variable degrees of depressed ventricular systolic function in DCM, depending on the stage of the disease.

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Figures 8a and 8b Subcostal four-chamber view: hypovolemia. a) Image at the end of diastole of the ventricles, showing their small sizes (compare with the centimeter scale). b) Same view as in (a) at the end of systole. The ventricular chambers have reduced in size so markedly that cavity obliteration (so called ‘‘kissing ventricle’’ or ‘‘kissing trabecular muscles’’) occurs due to the ventricular walls touching when emptying at end of systole. LL, left lobe of the liver; RA, right atrium; LA, cavities of right and left atria; RV, LV, cavities of right and left ventricles; IVS, interventricular septum.

sector will not be directed sufficiently toward the thorax – it will be too far towards the back, and so it will cross the heart tangentially or miss it completely.

(6) When you start the exam, do not watch the monitor of the ultrasound device at the beginning; instead, take care to place the probe correctly onto the patient first, and then look at the screen. Based

Figure 9. Hypovolemic patient during the early phase of a septic shock. Small area of the left ventricle at end of diastole (dotted circle) (a) and very small inferior vena cava (IVC) at end of expiration (b) give reliable clues regarding the hypovolemic hemodynamic profile of this hypotensive septic patient. Sequential volume challenge leads to improvement in cardiovascular status, and this is paralleled an increase in the size of the IVC (c, d).

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Figures 10a and 10b. Right heart dilatation as a typical finding in acute pulmonary embolism. a) Enlargement of the cavity of the right ventricle (RV). The interventricular septum in diastole is moving towards the left ventricle (LV). Note that the probe orientation shows an image of the subcostal four-chamber view alternative to the one obtained with the cardiological approach (apex on the right side of the screen). In this picture, obtained with the FAST approach, the heart is in fact displayed with the apex orientated to the left side of the screen. As yet, there is no agreement about which orientation should be used as a standard. b) In the subcostal short-axis view, the LV is compressed by the RV and is shaped like a capital D. This is due to acute pressure overload and dilatation of the RV, which also results in LV filling impairment.

on our training experiences, this prevents unintentional probe movement and unnecessary prolonged searches for the heart on the screen of the device without performing correct manipulation of the probe. When the subcostal approach is performed as described, the heart will be easily visualized in most patients. Only a few adjustments should then be necessary to obtain a regular four-chamber view. Better results are often obtained with the subcostal window rather than with apical or parasternal approaches in patients with pulmonary emphysema, those who are slightly overweight, and those with mechanical ventilation.

FEEL Algorithm Focused echocardiography evaluation in life support was developed originally for implementation in the resuscitation process. The FEEL algorithm was designed to integrate echocardiography into advanced (cardiac) life support (ALS, ACLS). Therefore, the FEEL protocol is essentially compliant with the 2005 ALS algorithm (Figure 6). This means keeping the hands-off time for chest compressions during CPR as

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brief as possible. Thus, all ALS-related procedures should always be established prior to echocardiography, and pauses should be no longer than the 10 s of the pulse check. The main challenge with the FEEL exam is to perform a visual estimation of cardiac function and gross pathologies by eye within a very limited time frame and under time pressure. Therefore, FEEL requires training [3, 15].

FEEL Exam The subcostal window may be best suited for practically performing the FEEL exam in a supine patient. FEEL is proposed to be a ten-step procedure, where the first seven steps are related to preparation only [3]. A crucial issue is that performing FEEL during resuscitation (when CPR chest compressions may be required) challenges the sonographer to perform the echocardiographic examination in no more than 10 s. The greatest priority during CPR cycles has always been to resume regular chest compressions. This can be achieved by acoustic assistance such as a verbal countdown (ten, nine, eight, seven, …) and by having one of the rescuers not involved in imaging control the length of the pause. Otherwise, in our experience, sonographers will not stop performing imaging in pauses of chest compression when they are untrained. However,

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Figure 11. Cardiac tamponade in a shocked patient with a ruptured left ventricular wall caused by mitral subannular abscess. Upper panels are subcostal four-chamber views showing clear evidence of RV diastolic collapse (a, inward displacement of the RV free wall, arrow) and of RA systolic collapse (b, inward displacement of the RA free wall, arrow). Hyperkinesia of both ventricles (see the systolic reduction in the sizes of the LV and RV from a to b) associated with fixed dilated inferior vena cava (c) is a typical finding of tamponade; it is a consequence of diastolic impairment due to high pericardial pressure, thus hindering venous return to the heart. After pericardial puncture, the drainage of even a small amount of blood restores hemodynamic stability (d, see the reduction in the distance between the two pericardial layers, arrow). RV, right ventricle; RA, right atrium; LV, left ventricle; LA, left atrium; IVC, inferior vena cava.

after a brief one-day training course, basic knowledge on keeping to time frames and exploiting the results of imaging to improve resuscitative efforts is implanted.

Pathology Few findings should be recognized when performing periresuscitation echocardiography [3, 15]. Pulseless Electrical Activity and Pseudo-pulseless Electrical Activity Pulseless electrical activity (PEA) is essentially an echocardiographic diagnosis. It is defined as an absence of wall motion despite regular electrical activity in the ECG [16]. This finding is comparable to the older term of electromechanical dissociation. In contrast, a pseudo-PEA is diagnosed if no pulse is palpable but regular wall motion is detected in the echocardiography.

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Severe Left Ventricular Dysfunction A typical example of high-graded limited global pump function is dilated cardiomyopathy (Figure 7). The gross appearance in a 2-D scan is the dilatation of all four chambers and global hypokinesia of the LV, depending on the disease state. Such a finding can be very easy to recognize. On the other hand, severe acute left ventricular dysfunction is indicated by hypokinesia in the absence of chamber dilatation, for example in acute myocardial infarction, or sepsis-related myocardial dysfunction. However, the reason for limited function may not be obvious following the qualitative assessment. Furthermore, a normal pump function does not rule out another pathology, such as valvular dysfunction. Hypovolemia Severe hypovolemia can be detected by detecting small, hyperkinetic, ventricular chambers. However,

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such an extreme example may not be seen regularly (Figure 8). A small inferior vena cava will confirm this diagnosis (Figure 9). Acute Cor Pulmonale Pulmonary embolism (PE) is a frequent complication in surgical patients. Echocardiography exhibits typical signs related to severe acute PE (Figure 10). However, direct visualization of the embolus is not the aim, and right heart pathology (septal flattening, paradoxical septal movement or right ventricular dilatation) can also be found in other diseases. Pericardial Effusion Various amounts of fluid can accumulate in the pericardial space (Figure 11). When fluid fills the pericardial space acutely, it increases the pressure in the pericardial sac; as a result, right and left ventricular filling can be immediately and dramatically impaired by small volumes. In contrast, when the fluid is generated over longer time periods, it can be compensated for by progressive distension of the pericardium, and no impairment of filling will be observed, even with pronounced amounts of fluid (Figure 11d). Thus, it depends not on the volume but on the time taken for the volume to enter the pericardial space. Pericardial fluid together with signs of compression of the lowpressure chambers (the atria and the right ventricle) may support a clinical diagnosis of cardiac tamponade (which remains a clinical diagnosis). These findings can be obtained quite easily. However, if in doubt, pericardial tamponade is the clinical diagnosis; this should lead to consequences such as volume infusion and transfer to a cardiology department, and should not be based on the image only. Although historically pericardial puncture has been largely reserved for cardiologists, emergency sonographic physicians should be prepared to perform pericardiocentesis when they are involved in imaging during resuscitation, because it can take too long to get an expert to the scene. Examples include penetrating chest injury, where we would highly suggest ruling out a pericardial effusion or tamponade. Pericardial effusions are also more frequent findings in medical patients in PEA or nearPEA states [17].

coupling, and ultrasound cannot be transmitted through the skin. Air in the stomach or bowels may also limit the use of the subcostal window.

Conclusion The subcostal window may be of great interest for the nonspecialist ultrasound performer because it is easy to apply in emergency cases in the supine position, can address the main pathologic findings, and is most suitable for extended examinations in addition to the FAST procedure. However, the requirement for resuscitation necessitates time-sensitive and ALS-conformed work flow as well as basic knowledge of it and training in its use before it is employed.

Conflict of interest statement The authors declare that there is no actual or potential conflict of interest in relation to this article.

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Address for Correspondence Raoul Breitkreutz, MD Clinics of Anesthesiology Intensive Care Medicine and Pain Therapy Hospital of the Johann Wolfgang Goethe-University Frankfurt am Main Germany e-mail: [email protected]

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