ultrasound in shock and peri-arrest · echo findings in tamponade •effusion with diastolic...
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Ultrasound in Shock & Peri-Arrest
Dr Bill Coode
Consultant in Emergency Medicine
• Discuss role of ‘shock scan’
• Focused Echo
• IVC assessment
• ‘Shock Scan’ protocol
• Clinical Cases
Why Ultrasound In Shock?
• Initially clinical diagnosis of shock etiology correct in only 50% patients
» Jones, A. CCM 2004;32(8):1703
Common Causes Of Shock
LVF Tension PTX Haemoperitoneum Hypovolemia
Tamponade PE Valvular Leaking AAA
Adrenal failure ThyrotoxicosisAortic
dissectionAnaphylaxis
Neurogenic
shockToxic ACS Arrhythmia
GI Bleed SepsisMesenteric
IschaemiaMetabolic
‘Shock Scan’
• FATE scan• Focus Assessed Transthoracic Echo
• ACES scan• Abdominal and Cardiac Evaluation with
sonography in Shock
Scanning Technique
FAST
AAA
PTX
HTX
Focused Echo
IVC assessment
ED U/S IN SHOCK
.
OCCULT BLEEDING
CI > 0.5
TACHY/HYPERKINESIS
TACHY/HYPERKINESISCI > 0.5
CARDIAC ACTIVITY
LV FAILURE
LUNG ROCKETS
RV STRAIN
EFFUSION /TAMPONADE
PNEUMOTHORAX (TENSION)
DVT
SOURCE?
Does it work?
• 15 mins after arrival to ED:– 50% correct diagnosis in clinical assessment group
– 80% correct diagnosis in ultrasound assessment group
• Scan time - 5.8 mins» Jones, A. CCM 2004;32(8):1703
Marker Conventions
Formal Echocardiography
What do we need to assess?• Pericardial effusion / tamponade
• Gross ventricular function» Normal
» Hypokinetic
» Hyperdynamic
• Atrial & ventricular size
Subcostal Echo
• Don’t need an echo probe– Can used curved array
• Suited to supine patients
Subcostal Echo
Liver
RVLV
‘Backup’ Views
• Long axis
• Short axis
• Apical
Parasternal Long Axis
RV
LVLA
Ao
Parasternal Short Axis
LVRV
Parasternal Short axis
Text
Echo made easy
S.Kaddoura
Parasternal
Short axis
Apical Four Chamber
LVRV
IVC Assessment
IVC Collapsibility
• M Mode
• Collapsibility index
Why assess IVC?
Reasonable Preload assessment
In reality, the middle is a grey zone.
- Flat, collapsing >50% or less than 1.5 cm diameter
Hypovolemia!!!
Distributive Shock
- Engorged, >2 cm, poorly collapsible IVC
Obstructive Shock: think PE, Tamponade
Cardiogenic: think Acute/Chronic, Acute on Chronic
NB: though well correlated with central pressure, not a good
predictor of fluid responsiveness
Chest - Haemothorax
Will identify pleural effusions
Lung Bases
Reliably detects as little as 50-100ml in the thorax
Sensitivity >96%, specificity 99-100%
Effusion assessment
Liver
Diaphragm
Pleural space
Haemothorax
liver
fluid
Pneumothorax
Summary - Shock Scan
Free fluid Abdominal
Pleural
Lung Pneumothorax
Aorta AAA
Pericardium
ECHO
IVC
Effusion Haemopericardium
Tamponade
Chamber size
Contractility
Collapsibility
Engorged
Others
• DVT
• Ruptured
ectopic
• Gallbladder
Clinical Cases
Case 1
• 67 year old female
• Presented following an episode of collapse
• 2 weeks increasing SOB and worsening ET
• 3 month Hx weight loss
• P - 115
• BP - 85/50
• RR - 22
• Temp 36.2
Hx
Obs • pH - 7.28
• Lactate - 5.2
• PaO2 - 9.6
• PaCO2 - 4.3
In
CXR
ECG
Differential?
Apical Echo
Drained 1.3L of exudate - malignant cells
Echo findings in Tamponade
• Effusion with diastolic collapse of any chamber
• Moderate / large effusion with clinical suspicion of tamponade
• Engorged, non-collapsible IVC
Case 2
• 58 year old male
• Blue call - OOH cardiac arrest
• PEA
• 4 x cycles CPR
• PMHx IHD
• DHx Amiodarone
Hx
PEA:‘True EMD’ vs Low CO state
• No mechanical activity very grave prognostic sign
– No survivors in series of 136
» Blavis, M. AEM 2001;8(6):616
Case 3
• 58 year old male
• Sudden onset chest pain and SOB
• Sedentary, lives in a single room
Hx
Obs In• P - 145
• BP - 75/50
• RR - 32
• pH - 7.28
• Lactate -
4.8
• PaO2 - 7.6
• PaCO2 - 4.1
CXR
ECG
Differential?
IVC
Echo
Diagnosis of massive PE
• RV dilatation (RV > LV)
• RV hypokinesis
• Paradoxical septal motion
– IVC engorgement (>2cm)
Case 4
• 81 yr old female
• Sudden onset chest pain
• Collapses in ambulance and has a seizure
• PEA Arrest
• 1cycle CPR + Fluid bolus
• P122 BP 64/- RR14
ECG
Diagnosis?
Ultrasound
CT
Case 5
• 56y old man
• Out playing poker
• Epigastric pain and dead leg
Case 6
• Morbidly obese 40yr old female
• 3 days Haemoptysis
• Hypotensive and tachycardic
• Previous DVT with multiple PEs
• Not anticoagulated
Vital Signs
• P119 BP 70/30
• RR22 SpO2 92% on 15LPM
• T 38.5
• ABG– pH 7.1
– PaCO2 6.2
– PaO2 7.5
– HCO3 14
– BE -10
ECHO / Ultrasound
• Underfilled IVC
• Normal RV
• Hyperdynamic circulation
• L lung base effusion
Investigations
Diagnosis
• Severe sepsis secondary to pneumonia
• Ultrasound diagnostic tap
Case 7
• 22 yr old female
• Collapse at home
• P 144 RR22 BP 76/52
• PEA arrest with LAS
FAST / SHOCK Scan
Diagnosis
• Ruptured ectopic
• Urgent laparotomy
21y Male ‘Silent Chest’
Questions?
Questions?
• Fate Card
• iPhone and Andriod
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