Pierre Kory, MPA, MDMedical Director, Trauma and Life Support Center

Chief, Critical Care ServiceAssociate Professor of Medicine

University of Wisconsin School of Medicine and Public Health

GOALS POINT-OF-CARE ULTRASOUND

BRIEF HISTORY – EVOLUTION - DEFINITION OVERVIEW OF THE 4 DOMAINS CRITICAL CARE ULTRASOUND

CRITICAL CARE ECHO – DIFFERENTIATION OF SHOCK STATES SEPTIC, HYPOVOLEMIC, CARDIOGENIC, OBSTRUCTIVE - DOES IVC HELP? CASE BASED OVERVIEW OF SHOCK SYNDROMES LITERATURE REVIEW SUPPORTING ECHO AS TOOL FOR DIAGNOSIS SHOCK STATES CARDIAC ARREST STATES – IS TEE THE FUTURE STANDARD OF CARE?

LUNG ULTRASOUND – DIFFERENTIATION OF ACUTE RESPIRATORY FAILURE ADDRESS WIDESPREAD INACCURACY IN DIAGNOSIS OF ARF INTRODUCE 5 ULTRASOUND SIGNS AND DEFINED PATTERNS OF ARF LITERATURE REVIEW OF IMPACT ON ACCURACY

**RESIDENT CASE SESSION – MORE PRACTICE ASSESSING CASES OF SHOCK USING ECHO

HISTORY OF BEDSIDE DIAGNOSTIC TECHNOLOGY

1808 – Laennec’s stethoscope 1888 - Reflex Hammer 1950 –Korean War – Bedside X-ray

1950’s –Ultrasound - Refrigerator size machines○ Research labs only

1960’s-70’s – commercial machines 1980’s – Movable, placed on carts 1990’s- DARPA grant – Backpack Ultrasound!

1990’s – Ultrasonography at the Bedside○ Birth of Point-of-Care Ultrasound○ Machines smaller, powerful, user friendly, ubiquitous○ Central venous access - further spread of machines

2000’s – Portable machines rival quality of largerNelson, Heart , 2013Noble, NEJM 2011

History of cardiac output monitoring in anesthesia

Scene from AMC Television Series “The Knick” about a NYC Surgeon in 1905

“Portable” X-Ray - 1952

“Portable” Ultrasound – 2016

THE LATEST ADVANCE… “FOREARM” ULTRASOUND

IMAGING POWER… IN YOUR HANDS

Miraculous Properties Penetrates through

fluid and solid organs

Liver, kidney, heart, spleen ( LUNG)

Obstructed by bone and air

**Image taken with lap-top sized machine, 2008,

A “DISRUPTIVE” INNOVATION

“That which transforms a market by introducing simplicity, convenience, accessibility, and affordability where complication and high cost were the status quo”

INITIALLY, Traditional imagers controlled market ○ expensive, immobile machines, interpreted remotely by experts

SUBSEQUENTLY, Technology led to Hand held/Portables – cheap, high quality images, easy to use, wider spectrum of doctors using the machines ○ devices shown to be of equal efficacy for “decision making”

Nelson, Heart , 2013

POINT-OF-CARE ULTRASOUND (POCUS)– SOME DEFINITIONS

“ultrasound exam performed by the care PROVIDER in real time” Not saved as a still image to be interpreted later by remote specialist

“not a complete study, rather an extension of the clinical examination to rule in or rule out key diagnoses in specific clinical settings”

“geared to addressing highly time-dependent and focused questions and, in general, most focused scans become more obviously positive as the patient becomes increasingly unwell”

Grifoni Chest 2013Atkinson J Emerg Med 2011

Stable vs. Unstable Patients

The benefits of point-of-care ultrasound: Unstable patients- directs immediate care and potentially

saves lives Stable patients - expedites care, reduces ancillary testing,

and educates providers.

Differences between Point-of-Care Ultrasound over Traditional Imaging Practice

• Avoid Clinical Disassociation of Traditional Interpreters• knowledge of loading conditions, pre-test probability of disease(s) in

question

• Avoid Time Disassociation of Traditional Interpretation• no delays in performance/interpretation by a remote specialist• avoid lengthy, “comprehensive” exams – focus components to those most

relevant

• Integrate Exam Findings From Multiple Organ Systems simultaneously-answer broader questions:

• Why is this patient in shock?• Why is this patient in respiratory failure?• Why does this patient not have urine output? • Why is the patient’s abdomen distended?• What are causing the bibasilar opacities?

4) Avoid potentially lethal radiation 5) Avoid potentially ”lethal” costs

POCUS EVOLUTION 1970’s – USA - Ultrasound first used at bedside of trauma patients 1980’s France – Birthplace of Critical Care Ultrasonography

○ ICU Echo in 1980’s, Lung and GCCUS – 1990’s TEE now performed as a routine assessment of shock patients

1990’s- “FAST” exam coined in Emergency Medicine in U.S○ Part of EM competency requirements since 1994○ Precedent for development of ever expanding POCUS applications○ POCUS now part of nearly every specialties practice

2000’s - Medical schools now integrating into curriculum○ Rare for Medicine Residency programs (some recent studies..)○ Pulmonary/Critical Care Programs – becoming routine

EVOLUTION OF POINT OF CAREULTRASONOGRAPHY (CCUS)

Soni, Arntfield, Kory, POCUS, 2014

GUIDELINES/RECOMMENDATIONS FOR USE OF ULTRASOUND

AMA – “ultrasound within scope of practice of (all) appropriately trained-physicians” AHCQR – one of 12 best practices for patient safety (CVC access) ACGME - required component of training in several residency and fellowships

PCCM Residency Review Committee recommends:○ “ training in ultrasound guided CVC and thoracentesis..”○ “demonstrate knowledge of ultrasound imaging techniques used in evaluation

of patients with pulmonary disease or critical illness” AIUM 2004 - “the concept of an ‘ultrasound stethoscope’ is rapidly moving from the

theoretical to reality.” Abraham Verghese - “great views of heart, adds volumes to info from stethoscope”

Advocates POCUS to improve patient interaction/PHYSICAL EXAM 2017 SURVIVING SEPSIS CAMPAIGN GUIDELINES:

CCUS Rationale/Evidence…? Improves safety & Success of venous, pleural, peritoneal,

pericardial cannulation and drainages Uncountable cases of unsuspected life-threatening conditions

(AMI, VTE/PE, pleuro-pericardial, valves, aorta, PTX, cardiomyopathy)

Large improvements in accuracy of diagnosis of shock and acute respiratory failure “suggestion” of improved outcomes

Sequential exams guide resuscitation, titration of inotropes Under-reported outcomes/benefits, captured in several studies

but not as primary outcomes – difficult to design studies on diagnostic tools

UNDER-RECOGNIZED IMPACT OF CRITICAL CARE ULTRASOUND: REDUCTION IN IMAGING TESTS

Peris A et al, Anaesth Analg, 2010 Introduced LUS to a group of intensivists. Measured CXR and CT scans

use 3 months before and after LUS training○ CT’s: 274 to 135 ( 50% decrease)○ CXR’s: 803 to 589 (40% decrease)○ *trend to a lower LOS, lower days on ventilator”

Oks M et al, Chest, 2014 Compared radiology tests between North Shore ICU (no diagnostic U/S)

and Long Island Jewish (heavy U/S use)○ 3.75 CXR/pt vs. 0.82 CXR/pt ( p<.05) ○ .1 CT/pt vs.04 CT/pt (p<.05) ○ .17 CT abdo/pt vs. .05 CT Abdo/pt (p<.05)

CRITICAL CARE ULTRASONOGRAPHY APPLICATIONS “WHOLE-BODY ULTRASOUND”

CARDIAC Differentiation of Shock States Assessment of Fluid Responsiveness?

LUNG and PLEURA Diagnosis of Causes of Acute Respiratory Failure Characterization/drainage of pleural pathology

ABDOMINAL Free Fluid, Obstructive Uropathy, Ischemic Colitis

VASCULAR Catheter Insertion Guidance Diagnosis of Deep Venous Thrombosis

BASIC CCE – RECOGNIZING SHOCK SYNDROMES

NEJM REVIEW 2012 –CATEGORIZING SHOCK STATES

Taken From NEJM Review Paper on Management of Shock, 2012

ASE PRESIDENT EDITORIAL ON POCUS 2016

email FROM FORMER RESIDENTS/FELLOWS 7/27/15 - I just wanted to email you and say a huge thank you for being a

great teacher to me during residency. Also, you were the first to introduce me to critical care ultrasound. I always knew it was an important tool but didn't realize it could be life saving until last week. I was called to evaluate a young 34 year old guy admitted only for cellulitis when he suddenly syncopized became tachycardic hypotensive and diaphoretic.

Everyone thought he had sepsis and started fluids but I used the ultrasound and was able to detect acute R heart strain and suspected a massive PE instead. He ended up arresting 3 times, was given full dose TPA, went to the OR and had massive clots pulled out his right and left PAs. He's now extubated with a full mental status and no Neuro deficits. “This is the first time I can honestly say I saved someone's life and it was all because I knew to use ultrasound.” I thought you'd appreciate the story and also wanted to tell you again how grateful I am to have had you as a teacher. Wisconsin is lucky!

COMPREHENSIVE VS. FOCUSED ECHO

Comprehensive Echo: More than 70 quantitative assessments provided Exactly zero of the quantitative measures are critical to answering the

VAST majority of ACUTE clinical questions (in a MICU at least)○ LA diameter, LV thickness, pressures, velocities, orifice sizes, strain rates,

regurgitation severities…○ It is a test invented in the quiet of an echo lab, tailored for diagnosis of chronic

and often subtle, vague, undifferentiated complaints or for the follow-up and MONITORING of patients with established and chronic cardiac disease

○ Every Comprehensive Echo has a summary list of statements that are identical to a FOCUSED echo report – this list is almost solely based on qualitativeassessments that can be made in minutes

MANY GOAL DIRECTED EXAM PROTOCOLS exist … all answer the same clinical questions..

Seif D, Critical Care Research and Practice, 2012A Divide between ED and Critical Care Patient Populations?

ASE, ACCP, and ACEP FOCUSED ECHO EXAM 5 Views 5 Assessments

Global LV size and function Global RV size and function Presence of Pericardial Effusion Intravascular Volume (IVC/LV/RV) Gross Valvular Structure/Fxn

*Pattern of findings allow for diagnosis of shock states

LV Function: Assessment of

Endocardial excursionMyocardial thickeningMitral valve movement

1. EndocardialExcursion

2. Myocardial Thickening

3. Mitral Valve Excursion

Images taken from Kory et al Point of Care Ultrasound 2014

Normal Size/Contractility of both LV and RV

SHOCK SYNDROME CASE 1

67 y.o male s/p admission for CVA complicated by PNA and respiratory failure, extubated, transferred to acute rehab floor

RRT called for dyspnea and hypotension

PARA-STERNAL LONG AXIS

RVOT

LV

PARA-STERNAL SHORT AXIS

RV

LV

NORMAL ECHOCASE ECHO

INFERIOR VENA CAVA

WHICH CATEGORY/PATTERN OF SHOCK IS PRESENT?

Vasodilatory Normal/Small Size LV/RV, Hyperdynamic vs Normal LVFNormal/Small IVC

CAT SCAN

THROMBECTOMY

SHOCK SYNDROME CASE 2

75 NHR a/w respiratory failure and shock Sepsis protocol started in ED based on urine pyuria Goal-Directed Echo Performed

PARA-STERNAL LONG AXIS

LV

RVOT

LA

NORMAL ECHO - PSLA

PARA-STERNAL SHORT AXIS

PACER WIRE

LV

RVNORMAL ECHO - PSSA

APICAL 4 CHAMBER

RV LV

RA LA

IVC VIEW

Patient hypoxemic, intubated, now oliguric

WHICH CATEGORY/PATTERN OF SHOCK IS PRESENT?

Vasodilatory Normal/Small Size LV/RV, Hyperdynamic vs Normal LVFNormal/Small IVC

SHOCK SYNDROME CASE 2

MULTIFACTORIAL SHOCK? Distributive by history Cardiogenic component - tolerated little fluids, poor reserve

○ Prompts more focus for occult/coexisting ischemia

Inotropic therapy indicated ○ UOP, lactate improved with antibiotics, inotropes, pressors

SHOCK SYNDROME CASE 3

72 year old woman presenting with fever, malaiseInitial Vitals T=102 Hr ‐ 122, BP ‐ 80/40, RR ‐ 26Sepsis protocol initiated, cultures drawn, antibiotics given,lactate = 5.23 Liters Crystalloid given, remained hypotensive to 86/42 ‐norepinephrine initiated, sent to ICU

RVOT

LV

IVC VIEW

SHOCK SYNDROME CASE #3

• GDE FINDINGS:• Normal LV size and function• Normal RV size and function• Absence pericardial effusion• Filled, Invariable IVC

SYNDROME: "Normal Echo” SHOCK = DISTRIBUTIVE, RESUSCITATED 

TREATMENT: ANTIBIOTICS/VASOPRESSORS

SHOCK SYNDROME CASE 4

74 y.o woman, sister of Board of Trustee Member, in hospital for severe Cdiff colitis, recovering. New DVT on anti‐coagulation.

Routine vital signs taken after dinner one Friday evening ‐ 80/40, HR ‐ 140, RR‐ 28, Afebrile, 97%

No complaints. Feels weak. LE edema on exam. Pallor. Rectal Exam ‐ brown stool.

PARA-STERNAL LONG AXIS

PARASTERNAL SHORT AXIS

APICAL 4 CHAMBER

IVC VIEW

SHOCK SYNDROME CASE 4 GDE Findings

LV – Hyperdynamic, collapsed chamber mid‐systole “kissing papillary” s RV – Small chamber, completely collapsible   Absence of Pericardial Effusion "Virtual" IVC

SYNDROME: HYPOVOLEMIC ( HEMORRHAGIC) SHOCK Source notable on para-sternal view!!? Treatment – hyper-aggressive fluid resuscitation, more IV lines,

pressure bags, blood bank run Despite aggressive approach, patient lost mental status, intubated, anuric – recovered 

without MOF over several days

EVIDENCE FOR GDE IN SHOCK PATIENTS

Initial studies – Largely in French/Mt. Sinai ICU’s Intensivist performed TEE, compared findings with PAC

○ Marked changes in diagnosis and therapy after TEE

Later studies - ED and ICU Studies of GDE with TTE Patients with Undifferentiated, Non-Traumatic Hypotension High Mortality – 18-26% in ED studies Poor ED Physician Clinical Accuracy

○ One study – ED physician correct initial diagnosis in only 26%

POCUS/GDE IN UNDIFFERENTIATED SHOCK IN THE MERGENCY DEPARTMENT Jones, Crit Care Med, 2004

184 non-trauma ED patients Intervention group received immediate GDE/FAST exam Control Group received delayed GDE/FAST Exam required 6 minutes Most likely diagnosis proved correct in 80% of ultrasound group Most likely diagnosis proved correct in only 50% control group

TIME FOR PART II????

ULTRASOUND IN THE DIAGNOSIS AND MANAGEMENT OF RESPIRATORY FAILURE **I have many more cases of shock representing the

spectrum of discrete patterns encountered in critical care, I will do these with the residents after Grand Rounds

IMPACT OF GDE-TEE IN SEPTIC SHOCK

Vieillard-Baron, 2012 Did GDE-TEE in 46 patients Used validated Echo criteria for determination of fluid

responsiveness, requirement for inotropes, vasopressors Compared Echo Protocol with Surviving Sepsis Protocol

○ 70% of patients – fluid plan in agreement○ 30% of patients – TEE mandated holding of fluids (despite CVP<12)

14 patients required inotropes by TEE ○ Only 4 would have gotten inotropes by SSCG

IMPACT OF GDE/LUS IN ED/ICU

Manno, Anesthesiology 2012 – 58% confirmed dx, 26% changed Pirozzi, Crit Care Ultrasound, 2014 – 50% wrong dx vs. 5% Silva, Chest, 2013 – 63% accurate initial dx vs 83% Bellone, 2013 – 57% accurate initial dx vs. 90.7%

5% vs 2.7% mortality… (P<.01)

All studies involved experienced POCUS clinicians All studies had high impact on initial diagnostic accuracy

○ “Heart-Lung ultrasound exam is mandated in all patients presenting with cardiopulmonary failure” – Kory, 2013

2015 AHA GUIDELINES FOR ACLS

Physiologic Monitoring During CPR: … we suggest that if cardiac ultrasound can be performed

without interfering with the standard advanced cardiovascular life support protocol, it may be considered as an additional diagnostic tool to identify potentially reversible causes of cardiac arrest

How does one do cardiac ultrasound without interfering with ACLS protocols in arrest patients..??

• 54 TEE’s done by 12 ED physicians ( 4 hour simulation course)• 43% done in cardiac arrest patients

• 78% influenced diagnosis• 67% impacted therapeutics

TEE DURING CPR IN THE ED BY EP’s

TEE during CPR – Arntfield et al, 2016

Therapeutic impact in 67% of cases Change to quality/timing/location of CPR (43%).

○ Misplaced vector of force (in both manually and automated delivery of CPR), identification of chest compressor fatigue, shortened pulse-check duration, and identification of return cardiac activity during CPR were all described.

TEE findings were additionally noted to influence prognosis and cessation of resuscitation (30%), and guide hemodynamic support either through volume (18%) or vasoactive drugs (8%) (Figure 3).

WHAT IS WRONG WITH THE CPR BEING DELIVERED HERE?

TEE CPR WITH LVOTO

IS THERE ANY BLOOD GETTING TO THE BRAIN?

First Textbook covering all aspects of POCUS – print and electronic/IPAD version….

There are Endless Uses for Ultrasound in Both Critical Care and Pulmonary Practice

Differentiating Cardiogenic vs. Non-Cardiogenic Pulmonary Edema Ruling out out Pulmonary Embolism as cause of shock/hypoxemia/dyspnea Evaluation of full stomach pre-intubation Evaluation for ischemic bowel – absence/presence of peristalsis Rule out of obstructive uropathy Evaluation for free fluid in abdomen Transthoracic needle biopsies of ANY pleural or peripheral lung based mass Chest tube placement into lung abscess ECMO catheter placememt Hemidiaphragm assessments Extubation planning and quantification of lung water Screening for elevated intracranial pressure

And the list grows..