I Will Be at Your (Bed)Side – The Role of Bedside Echocardiography for Non-Cardiologists

Abstract

As the availability of portable echocardiographic equipment is becoming more and more widespread, physicians can add a powerful tool to their bedside examination skills, thus helping them to more effectively face the growing complexity of patients admitted to internal medicine departments or the emergency room. Focused cardiac ultrasound (FoCUS) can be defined as a goal-directed, simplified, qualitative examination performed at the bedside using portable echocardiographic devices. FoCUS is not meant to be a substitute for a standard 2D color Doppler echocardiographic examination. Nevertheless, it can provide rapid and reliable information when limited to basic questions, even when performed by non-cardiologists with brief training. Furthermore, a focused cardiac ultrasound examination maximizes its diagnostic role when integrated with an ultrasonographic assessment of the lung, abdomen and deep veins, in a multisystem approach that is particularly dear to internists. In this article, we will focus on the specific targets of a focused cardiac ultrasound examination, as well as the most common pitfalls that can be encountered in ultrasonographic practice. We will also address the application of FoCUS in the management of two typical scenarios in clinical practice, such as dyspnea and non-post-traumatic hypotension.

Zusammenfassung

Mit der zunehmenden breiten Verfügbarkeit tragbarer echokardiografischer Geräte können Ärzte eine leistungsstarke Methode hinzufügen, um ihre Fähigkeiten in der bettseitigen Untersuchung zu erweitern. So können sie der wachsenden Komplexität der Patienten, die in den Abteilungen für Innere Medizin oder in der Notaufnahme aufgenommen werden, wirksamer begegnen. Fokussierter kardialer Ultraschall (FoCUS) kann als zielgerichtete, vereinfachte, qualitative Untersuchung definiert werden, die am Krankenbett mittels tragbarer Echokardiografie-Geräte durchgeführt wird. FoCUS ist kein Ersatz für eine standardmäßige echokardiografische 2D-Farbdoppler-Untersuchung. Dennoch kann er bei Beschränkung auf grundlegende Fragestellungen schnelle und zuverlässige Informationen liefern, selbst wenn kurz ausgebildete Nicht-Kardiologen ihn durchführen. Darüber hinaus wird der diagnostische Wert des fokussierten kardialen Ultraschalls maximiert, wenn dieser in eine sonografische Beurteilung von Lunge, Abdomen und tiefen Venen integriert wird, und zwar in einem Multisystemansatz, der Internisten besonders am Herzen liegt. In diesem Artikel konzentrieren wir uns auf die spezifischen Ziele einer fokussierten kardialen Ultraschalluntersuchung sowie auf die häufigsten Fallstricke, die in der Ultraschallpraxis auftreten können. Wir werden uns auch mit der Anwendung von FoCUS bei der Behandlung von 2 typischen Szenarien in der klinischen Praxis befassen – Dyspnoe und nichtposttraumatische Hypotonie.

• References

• 1 Kimura BJ. Point-of-care cardiac ultrasound techniques in the physical examination: Better at the bedside. Heart 2017; 103: 987-994
• 2 Via G, Hussain A, Wells M. et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr 2014; 27: 683.e1-683.e33
• 3 Atkinson PR, Beckett N, French J. et al. Does Point-of-care Ultrasound Use Impact Resuscitation Length, Rates of Intervention, and Clinical Outcomes During Cardiac Arrest? A Study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators. Cureus 2019; 11: e4456
• 4 Mantuani D, Frazee BW, Fahimi J. et al. Point-of-Care multi-organ ultrasound improves diagnostic accuracy in adults presenting to the emergency department with acute dyspnea. West J Emerg Med 2016; 17: 46-53
• 5 Melamed R, Sprenkle MD, Ulstad VK. et al. Assessment of left ventricular function by intensivists using hand-held echocardiography. Chest 2009; 135: 1416-1420
• 6 Michalski B, Kasprzak JD, Szymczyk E. et al. Diagnostic utility and clinical usefulness of the pocket echocardiographic device. Echocardiography 2012; 29: 1-6
• 7 Razi R, Estrada JR, Doll J. et al. Bedside hand-carried ultrasound by internal medicine residents versus traditional clinical assessment for the identification of systolic dysfunction in patients admitted with decompensated heart failure. J Am Soc Echocardiogr 2011; 24: 1319-1324
• 8 Arienti V, Di Giulio R, Cogliati C. et al. Bedside Ultrasonography (US), Echoscopy and US Point of Care as a new kind of stethoscope for Internal Medicine Departments: the training program of the Italian Internal Medicine Society (SIMI). Intern Emerg Med 2014; 9: 805-814
• 9 Cardim N, Dalen H, Voigt JU. et al. The use of handheld ultrasound devices: A position statement of the European Association of Cardiovascular Imaging (2018 update). Eur Heart J Cardiovasc Imaging 2019; 20: 245-252
• 10 Hellmann DB, Whiting-O’Keefe Q, Shapiro EP. et al. The rate at which residents learn to use hand-held echocardiography at the bedside. Am J Med 2005; 118: 1010-1018
• 11 Spencer KT, Kimura BJ, Korcarz CE. et al. Focused cardiac ultrasound: Recommendations from the american society of echocardiography. J Am Soc Echocardiogr 2013; 26: 567-581
• 12 Lang RM, Badano LP, Mor-Avi V. et al. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American society of echocardiography and the European association of cardiovascular imaging. Eur Heart J Cardiovasc Imaging 2015; 16: 233-271
• 13 Rudski LG, Lai WW, Afilalo J. et al. Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography. Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and. J Am Soc Echocardiogr 2010; 23: 685-713
• 14 Lang RM, Bierig M, Devereux RB. et al. Recommendations for chamber quantification. Eur J Echocardiogr 2006; 7: 79-108
• 15 Labovitz AJ, Noble VE, Bierig M. et al Focused cardiac ultrasound in the emergent setting: A consensus statement of the American society of Echocardiography and American College of Emergency Physicians. In: Journal of the American Society of Echocardiography 2010; 1225-1230
• 16 Kimura BJ, Amundson SA, Willis CL. et al. Usefulness of a hand-held ultrasound device for bedside examination of left ventricular function. Am J Cardiol 2002; 90: 1038-1039
• 17 Mark DG, Ku BS, Carr BG. et al. Directed bedside transthoracic echocardiography: preferred cardiac window for left ventricular ejection fraction estimation in critically ill patients. Am J Emerg Med 2007; 25: 894-900
• 18 Hu K, Liu D, Niemann M. et al. Methods for assessment of left ventricular systolic function in technically difficult patients with poor imaging quality. J Am Soc Echocardiogr 2013; 26: 105-113
• 19 Marbach JA, Almufleh A, Di Santo P. et al. Comparative accuracy of focused cardiac ultrasonography and clinical examination for left ventricular dysfunction and valvular heart disease. Ann Intern Med 2019; 171: 264-272
• 20 Abe Y, Ito M, Tanaka C. et al. A novel and simple method using pocket-sized echocardiography to screen for aortic stenosis. J Am Soc Echocardiogr 2013; 26: 589-596
• 21 Shmueli H, Burstein Y, Sagy I. et al. Briefly trained medical students can effectively identify rheumatic mitral valve injury using a hand-carried ultrasound. Echocardiography 2013; 30: 621-626
• 22 Baumgartner H, Hung J, Bermejo J. et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eur J Echocardiogr 2009; 10: 1-25
• 23 Brennan JM, Blair JE, Goonewardena S. et al. Reappraisal of the Use of Inferior Vena Cava for Estimating Right Atrial Pressure. J Am Soc Echocardiogr 2007; 20: 857-861
• 24 Klein AL, Abbara S, Agler DA. et al. American society of echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: Endorsed by the society for cardiovascular magnetic resonance and society of cardiovascular computed tomography. J Am Soc Echocardiogr 2013; 26: 965-1012
• 25 Zanobetti M, Scorpiniti M, Gigli C. et al. Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED. Chest 2017; 151: 1295-1301
• 26 Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure the BLUE protocol. Chest 2008; 134: 117-125
• 27 Carlino MV, Paladino F, Sforza A. et al. Assessment of left atrial size in addition to focused cardiopulmonary ultrasound improves diagnostic accuracy of acute heart failure in the Emergency Department. Echocardiography 2018; 35: 785-791
• 28 Fields JM, Davis J, Girson L. et al. Transthoracic Echocardiography for Diagnosing Pulmonary Embolism: A Systematic Review and Meta-Analysis. J Am Soc Echocardiogr 2017; 30: 714-723.e4
• 29 Le Gal G, Righini M, Sanchez O. et al. A positive compression ultrasonography of the lower limb veins is highly predictive of pulmonary embolism on computed tomography in suspected patients. Thromb Haemost 2006; 95: 963-966
• 30 Nazerian P, Vanni S, Volpicelli G. et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest 2014; 145: 950-957
• 31 Jones AE, Tayal VS, Sullivan DM. et al. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med 2004; 32: 1703-1708
• 32 Cecconi M, De Backer D, Antonelli M. et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med 2014; 40: 1795-1815
• 33 Rhodes A, Evans LE, Alhazzani W. et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med 2017; 45: 486-552
• 34 Kearns MJ, Walley KR. Tamponade: Hemodynamic and Echocardiographic Diagnosis. Chest 2018; 153: 1266-1275 . Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/29137910
• 35 Kucher N, Luder CM, Dörnhöfer T. et al. Novel management strategy for patients with suspected pulmonary embolism. Eur Heart J 2003; 24: 366-376
• 36 Meredith EL, Masani ND. Echocardiography in the emergency assessment of acute aortic syndromes. Eur J Echocardiogr 2009; 10: i31-i39
• 37 Nazerian P, Mueller C, Vanni S. et al. Integration of transthoracic focused cardiac ultrasound in the diagnostic algorithm for suspected acute aortic syndromes. Eur Heart J 2019; 40: 1952-1960
• 38 Airapetian N, Maizel J, Alyamani O. et al. Does inferior vena cava respiratory variability predict fluid responsiveness in spontaneously breathing patients?. Crit Care 2015; 19: 400
• 39 Lichtenstein D. FALLS-protocol: lung ultrasound in hemodynamic assessment of shock. Hear lung Vessel 2013; 5: 142-147 . Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/24364005%0A, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC3848672
• 40 Antonucci E, Fiaccadori E, Donadello K. et al. Myocardial depression in sepsis: From pathogenesis to clinical manifestations and treatment. J Crit Care 2014; 29: 500-511
• 41 Soldati G, Testa A, Sher S. et al. Occult traumatic pneumothorax: Diagnostic accuracy of lung ultrasonography in the emergency department. Chest 2008; 133: 204-211
• 42 Vignon P, Mücke F, Bellec F. et al. Basic critical care echocardiography: Validation of a curriculum dedicated to noncardiologist residents. Crit Care Med 2011; 39: 636-642
• 43 Kanji HD, Mccallum JL, Bhagirath KM. et al. Curriculum development and evaluation of a hemodynamic critical care ultrasound: A systematic review of the literature. Crit Care Med 2016; 44: e742-e750
• 44 Labbé V, Ederhy S, Pasquet B. et al. Can we improve transthoracic echocardiography training in non-cardiologist residents? Experience of two training programs in the intensive care unit. Ann Intensive Care 2016; 6: 44
• 45 Kobal SL, Lior Y, Ben-Sasson A. et al. The feasibility and efficacy of implementing a focused cardiac ultrasound course into a medical school curriculum. BMC Med Educ 2017; 17: 94
• 46 Galusko V, Khanji MY, Bodger O. et al. Hand-held ultrasound scanners in medical education: A systematic review. J Cardiovasc Ultrasound 2017; 25: 75-83
• 47 Kimura BJ, Sliman SM, Waalen J. et al Retention of Ultrasound Skills and Training in “Point-of-Care” Cardiac Ultrasound. In: Journal of the American Society of Echocardiography 2016; 992-997