The Echo in ACS

    NextPrevious

    The Echo in ACS

    Case – 70 year old male mhx of HTN, IDDM presents with 2 hours of exertional chest pain. His ECG in triage is unremarkable for any ischemic changes. He appears uncomfortable and over the next 30 minutes requires escalating doses of nitroglycerin for chest pain. A repeat ECG is unchanged. You decide to echo him to look for a regional wall motion abnormality.

    Question – What is the benefit of looking for regional wall motion abnormalities? What is a systematic way to approach this task?

    ACS patients often have a non-specific ecg and early negative troponins despite significant coronary occlusion. Regional wall motion abnormalities (e.g. decreased contractility of a specific segment of ventricle) may be the first sign of occult coronary thrombosis. Finding it tunes you into the possibility that the patient may require an early invasive intervention, or at the very least a cath consult.

    Cardiologists and trained echocardiographers look at 17 segments of wall motion during an echo. This can be simplified into a 3 part evaluation:

    Coronary Artery Territories:

    1. Blue = lateral wall = L Circumflex (L Cx)
    2. Yellow = inferior wall = RCA
    3. Red = anterior wall = LAD

    Source – EMDocs

    (Source – ACEPNow)

    Guidelines:

    1. Best View – Parasternal Short at level of papillary muscles [3].
    2. Contractility can be described as normal, hypokinetic, or akinetic relative to other segments of the ventricle. In a normal ventricular contraction, the segment becomes symmetrically thick as it contracts inward. In areas of dyskinesis, this response is blunted.
    3. Caveats:
      1. Distinguishing between old and new regional wall motion abnormalities is very challenging.
      2. Mechanical and conduction system abnormalities may mimic wall motion abnormalities (e.g. Takotsubos, focal myocarditis, LV Aneurysm)

    Anterior Wall Motion Abnormality: (Pathology on L hand side). Source = Regional Wall Motion Asssessment (Teran/Vanyo)

    Watch Felipe Teran and Lara Vanyo’s excellent short-talk on this if you’d like to learn more.

    Resources:

    1. US Probe: Ultrasound for Regional Wall Motion Abnormalities (EMDocs)
    2. Regional Wall Motion Assessment (Felipe Teran, Lara Vanyo)
    3. ACEPNow – Detect Regional Wall Motion Abnormalities by POC Echo
    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • Difficult placement of an OGT? Try an ET tube introducer

      Tl;dr: Failed OGT placement in an intubated patient is common. Try using an 8.0 ETT as an introducer into the esophagus to prevent coiling in the mouth / upper esophagus.   Placement of an OGTRead more

    • Applying the Pelvic Binder: Pearls and Pitfalls

      Tl;dr: (1) Never rock the pelvis. Firmly squeeze and hold. (2) Consider quickly assessing for rectal or vaginal bleeding prior to binder application as this would suggest an open fx into the vag / rectalRead more

    • Don’t Be Rash

      Do you ever have a patient with a rash you just don’t recognize?  If you’re like me, it happens all the time and it can be hard to organize your differential.  Michelle Lin (https://aliemcards.com/cards/rash-unknown) published a greatRead more

    • Buprenorphine Band Wagon

      Do you know David Cisewski?  He’s incredible and he’s written an incredible review on buprenorphine (http://www.emdocs.net/buprenorphine-where-do-we-stand/) that I’d like to tell you all about. Buprenorphine marketed as Suboxone (but soon to be generic) is a mu-opioid receptor partialRead more

    • Ultrasound and Found

      Ultrasound for kidney stone has always been confusing.  If we do the ultrasound and find no hydro, don’t we need the CT to rule an alternate diagnosis?  If we do the ultrasound and find hydro, don’t weRead more

    • Old Graft? New friend!

      ESRD patients are typically “hard sticks.”   The arm with the fistula is typically off limits (unless in emergency settings) and the other arm is either difficult to access or occasionally has an old fistula. ThisRead more

    • The Supraclavicular Subclavian

      Traditionally, central line placement in the subclavian vein (SCV) involves a landmark-based approach in which the needle is guided under the clavicle. For the U/S lovers, there is an alternative approach to the subclavian inRead more

    • Paper Review: Are we hurting patients via oxygen supplementation?

      Bottom line up front: A recent large, high quality meta-analysis reported a significant mortality effect with the use of liberal, rather than conservative, oxygen supplementation. The number needed harm for 30-day mortality was 1 inRead more

    NextPrevious