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300 oracic ultrasound
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81. Soldati G, Copetti R, Sher S. Sonographic interstitial syndrome: the sound of lung water. J Ultrasound
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302 oracic ultrasound
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83. Raghavendran K, Notter RH, Davidson BA et al. Lung contusion: inflammatory mechanisms and
interaction with other injuies. Shock 2009; 32: 122-130.
84. Copetti R, Soldati G, Copetti P. Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovasc Ultrasound 2008; 6: 16.
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87. Miller PR, Croce MA, Bee TK et al. ARDS after pulmonary contusion: accurate measurement of contu-ARDS after pulmonary contusion: accurate measurement of contusion volume identifies high-risk patients. J Trauma 2001; 51: 223-228.
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89. Stern E. Imaging of blunt and penetrating trauma to the pulmonary parenchima. In: oracic Trauma and
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93. Sirmali M, Turut H, Topcu S et al. A comprehensive analysis of traumatic rib fractures: morbidity,
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94. Flagel B, Luchette F, Reed R et al. Half a dozen ribs: the breakpoint for mortality. Surgery 2005; 138:
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97. Livingston DH. Prevention of ventilator associated pneumonia. Am J Surg 2000; 179: 12S.
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100. Pasquale M, Fabian TC. EAST ad hoc Committee on Practice Management Guideline Development.
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101. Horton TG, Cohn SM, Heid MP et al. Identification of trauma patients at risk of thoracic aortic tear
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114. Rozicky GS, Feliciano DV, Ochsner MG et al. e role of ultrasound in patients with possibile penetrating cardiac wounds: a prospective multicenter study. J Trauma 1999: 46: 543-551.
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304 oracic ultrasound
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➤ Updated Bibliography
Rodriguez RM, Anglin D, Langdorf MI, Baumann BM, Hendey GW, Bradley RN, Medak AJ, Raja AS,
Juhn P, Fortman J, Mulkerin W, Mower WR. NEXUS chest: validation of a decision instrument for selective
chest imaging in blunt trauma. JAMA Surg 2013;148:940-946.
Validation of the NEXUS Chest decision instrument, which may safely reduce the need for traditional chest imaging
in blunt trauma patients older than 14 years.
Chung JH, Cox CW, Mohammed TL, Kirsch J, Brown K, Dyer DS, Ginsburg ME, Heitkamp DE, Kanne
JP, Kaerooni EA, Ketai LH, Ravenel JG, Saleh AG, Shah RD, Steiner RM, Suh RD. ACR appropriateness
criteria blunt chest trauma. J Am Coll Radiol 2014;11:345-351.
ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every
2 years by a multidisciplinary expert panel. is publication include an extensive analysis of current medical
Ku BS, Fields JM, Carr B, Everett WW, Gracias VH, Dean AJ. Clinician performed bedside ultrasound for
the diagnosis of traumatic pneumothorax. West J Emerg Med. 2013;14:103-108.
Alrajab S, Youssef AM, Akkus NI, Caldito G. Pleural ultrasonography versus chest radiography for the
diagnosis of pneumothorax: review of the literature and meta-analysis. Crit Care 2013;17:R208.
Ianniello S, Di Giacomo V, Sessa B, Miele V. First line sonographic diagnosis of pneumothorax in major
trauma: accuracy of EFAST and comparison with multidetector computed tomography. Radiol Med 2014.
oracic ultrasound and EFAST are rapid and accurate diagnostic tools for the diagnosis of traumatic pneumothorax. ese results support the previous Investigation in this field.
Oveland NP, Soreide E, Lossius HM, Johannesen F, Wemmelund KB, Aagaard R, Sloth E. e intrapleural
volume threshold for ultrasound detection of pneumothoraces: an experimental study on porcine models.
Scand J Trauma Resusc Emerg Med 2013;21:11.
e mean threshold volume to confirm the diagnosis of pneumothorax using ultrasound is 18 ml (standard deviation
of 13 ml). Lung ultrasound is very accurate in diagnosing small pneumthorax.
Bock JS, Benitez RM. Blunt cardiac injury. Cardiol Clin 2012;30:545-555.
A review on blunt cardiac trauma.
Williams SR, Perera P, Gharahbaghian L. e FAST and EFAST in 2013: Trauma ultrasonography: overview,
practical techniques, controversies and new frontiers. Crit Care Clin 2014;30:119-150.
is article reviews important literature on the FAST and EFAST examination in adults.
Costantino M, Gosselin MV, Primack SL. e ABC’s of thoracic trauma imaging. Seminars Roentgen
2006;209-225.
Ziegler K, Feeney JM, Desai D, Sharpio D, Marshall WT, Twoig M. Retrospective review of the use and
costs of routine chest X-rays in a trauma setting. Journal of Trauma Management & Outcomes 2013;7:2.
Two papers addressing the use of chest X-ray and chest CT in the trauma setting.
10
Echocardiography
Today cardiac ultrasound may concern various specialists: cardiologists,
emergency physicians, intensivists, traumatologists, pediatricians and
pulmonologists. ere is now evidence that echocardiography will improve the diagnostic potential in different settings with a positive impact
on patient management
Cardiac ultrasound is integrated with thoracic ultrasound in a goaldirected multidistrict diagnostic approach, without any specialization
distinction. is approach produces essential data, confirming the presence of pericardial fluid, valvular abnormalities, and enlargement of the
heart chambers.
In addition, it can directly define a rise in the central venous pressure,
the global and segmental cardiac contractility and the pressure gradients
in the heart chambers through the valves. Finally, echocardiography may
indicate the etiology of altered hemodynamics (see Chapter 11).
1,2,3
.
➣ Machines
In the last few years a wide variety of ultrasound machines for cardiovascular use have been
developed. ey may be classified in four categories:
• Stationary high-end systems, fully equipped with 3D and other advanced modalities.
• Mobile systems, equipped with standard modalities and easily transportable inside health
care facilities.
• Portable machines offering essential modalities to perform a complete echo study.
• Pocket-size hand-held imaging devices.
Portable machines and pocket-size hand-held imaging devices are instruments useful for
basic applications of echocardiography (Focused Cardiac Ultrasound). ey are used when
echocardiography is limited in scope and problem-oriented (cardiovascular assessment to
complement the physical examination).
Mobile systems are easily transported to the bedside and offer full range of standard echo
modalities and measurements (M-Mode, 2D, Color, Pulsed and Continuous Dopppler, Tissue
Doppler). A small, but complete echo machine with all conventional tools, is necessary for intermediate or advanced bedside applications, or for a comprehensive hemodynamic assessment.
305
306 oracic ultrasound
e principles that affect the images of the heart in echocardiography, are those of general
ultrasound2. However in echocardiography, the return ultrasonic signals can be converted
into two types of representation: M-Mode and two-dimensional (2D).
In M-Mode scans a thin ultrasonic beam, immediately below the transducer, displays points
generated by tissue interfaces with a variable brightness in relation to the acoustic impedance.
e image generated allows to capture precise measurements related to the wall thickness, in
a time motion (M) manner (plotting movements against time).
Moreover, M-Mode examination allows the evaluation of structures that move quickly, such
as heart valves, with an accurate timing of cardiac events, correlated with ECG.
Two-dimensional images are more familiar to non-cardiologists. ey represent the cardiac
anatomy in real time, as “salami slices”, with variously oriented sections through walls, septa
and heart chambers. is kind of imaging highlights the heart anatomy, the cardiac kinetic,
the systolic function or the presence of intracavitary masses.
Pulsed and continuous Doppler and color Doppler functions are essential for the evaluation
of flows, gradients and to estimate valve areas.
In the following pages of this chapter reference will be made to two-dimensional
ultrasonography.
➣ Questions
e situations that emergency or ICU physicians often have to deal with, require instant
answers to very specific questions (may a cardiac tamponade be the cause of a state of shock?
May pulmonary embolism be the cause of severe dyspnea and hypoxemia?). Obtaining a
rapid response to clinical questions of this type requires right decisions in a short time and
it often impacts heavily on the patient outcome.
e knowledge required to perform goal-directed echocardiographic investigations is less
complex and extensive than the systematic knowledge of the cardiologist4. In this context,
questions about critical cases are simple and designed to quickly get essential information:
• Right ventricle: is it small? large? does it move?
• Left ventricle: is it small? large? does it move?
• Pericardium: is there fluid? is there tamponade?
• Valves: stenosis? regurgitation?
• Inferior vena cava: mobile? dilated?
• Lung: dry? wet?
is chapter is not meant to be a summary on echocardiography, for which we refer the
reader to the many existing texts on the subject, but it rather wants to be a complement to
pleural and lung ultrasound and a help to draw useful information for the management of
some critical syndromes of emergency and intensive care medicine.
➣ Methods of image capture
For cardiac ultrasound, sector transducers with median frequency of 3.5 MHz (2.5 to
5 MHz) are used.
Echocardiography 307
e probe is located in specific regions and generates standard sections of the heart and the
roots of the great vessels. e calibration of the machine should be adjusted to a low dynamic
range, so as to generate more black and white, and images appear on the screen inverted
horizontally compared to the images in abdominal and pelvic ultrasound. e lung is the
main obstacle for the visualization of the heart. It is therefore necessary to position the probe
on the chest on the cardiac acoustic windows, that facilitate exploration.
ere are four acoustic windows for cardiac examination: subcostal, apical, parasternal and
suprasternal (Figs. 1-4).
Figure 1 – Subcostal acoustic window.
Figure 2 – Apical acoustic window.
Figure 3 – Parasternal acoustic window.
308 oracic ultrasound
Figure 4 – Suprasternal acoustic window.
To obtain the subcostal scan the probe is placed in the epigastrium and directed toward the
left shoulder. For the apical scan, it is placed at the tip heartbeat, in the 4th-6th left intercostal space along the mid-clavicular line and directed toward the right shoulder. To obtain
the parasternal scan, it is placed in the 2nd-5th intercostal space along the left parasternal
line. Finally, for the suprasternal scan the probe is located at the level of the jugular notch.
For each of these approaches the visualization of the heart will be possible according to different projections: long axis, short axis, 4 and 5 chambers axis5 (Fig. 5).
PARASTERNAL
SUBCOSTAL
4 CHAMBERS
SHORT AXIS
LONG AXIS
APICAL
Figure 5 – Approaches and axis for the visualization of the heart.
Subcostal scans
e subcostal scan allows visualization of the heart through different angles and scanning
planes.
Echocardiography 309
Orientation along the short axis
Starting from a scan aligned with the course of the caval veins, continuous projections are
performed in the cranio-caudal and medial-lateral direction, from the base to the apex of
the heart.
. L (F. ) (C ).
LIVER
RIGHT ATRIUM
Figure 6 – Subcostal scan: long axis vena cava.
Clip 1 – Subcostal long axis caval vein scan.
. S (F. ) (C ).
INFERIOR VENA CAVA
RIGHT ATRIUM
SUPERIOR VENA
CAVA
RIGHT VENTRICLE
PULMONARY ARTERY
Figure 7 – Subcostal scan: short axis aorta.
Clip 2 – Subcostal short axis aorta scan.
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