ultrasound workshop aecem.kkh.go.th/download2/aec2_ultrasound workshop.pdf · 2019. 3. 11. · the...
TRANSCRIPT
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Ultrasound Resuscitation
Porntipa Tantibundit , MD.Department of Emergency Medicine , Khon Kaen Hospital
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What is shock ?
- Situation where oxygen transport is inadequate to meet the body’s oxygen demand - Reduced cardiac output, a determinant of oxygen transport
- Clues from the patient’s history, physical examination, and key laboratory tests
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What is shock ?
- Hypovolemic shock - Septic shock - Cardiogenic shock - Obstructive shock - Anaphylactic shock
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What is shock ?
- Initially managed with basic resuscitation measures - Bedside ultrasound should be performed if hemodynamic instability persists or to determine the etiology of shock
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Ultrasound The major ultrasound protocols for medical shock assessment
Protocol FALLS FATE FEEL resus FEER FREE POCUS RUSH-HIMAP
RUSH Trinity
cardiac 3 1 1 1 1 3 1 1 1
IVC 4 4 2 2
FAST 1 3 3
aorta 5 4 7 3
pneumothorax 2 2 5 6 2
pleural eff 2 4
pul edema 1 6 5
DVT 7 8
ectopic preg 8
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Rush Exam
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“ The Pump”
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Rush Exam
The first stepGoal -directed echocardiogramPericardial effusion LV functionRV dilatation
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Rush Exam
Position A• Parasternal long axis • Parasternal short axis
Position B• Subxiphiod
Position C • Apical view
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Parasternal long axis
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Parasternal short axis
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Apical view
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Subxiphoid view
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Pericardial effusion
First, the pericardial sac should be visualizedMay be confused with a pleural effusion The next step is to evaluate the heart for signs of tamponade Focuses on the movement of the right atrium and ventricle during
diastolic filling
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Pericardial effusion
Intrapericardial p > Intracardiac p
intrapericardial p > RA diastolic p intrapericardial p > RV diastolic p
Late diastolic RA inversion Early diastolic RV collapse
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Pericardial effusion
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Pericardial effusion
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LV contractility
Rapid determination of the strength of the pump Visual estimation of the volume change from diastole to systole Normal, mild-moderately decreased, or severely decreased and hyperkinetic The anterior mitral leaflet can be seen in the parasternal long-axis view touching or closely approaching the septal endocardium in early diastole
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LV contractility
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Right Ventricular size
Left- to-Right ventricle is 1 : 0.6 Dilation of the right ventricleInter-ventricular septum toward the left ventricleEvaluation of the leg veins for a deep vein thrombosis
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Right Ventricular size
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Right Ventricular size
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“The Tank”
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The TankPosition A
- IVC
Position B
- FAST / RUQ/ Pleural
Position C
- FAST/LUQ/Pleural
Position D
-FAST/Pelvis
Position E
-Lungs
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The Tank
Fullness of the tank Respiratory dynamics of IVCEstimate the central venous pressure (CVP)Approximately 2 cm from the junction of
the right atrium and the IVC
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The tank
M-mode sonography of the IVC provides an excellent means to measure The intubated patient , the respiratory dynamics of the IVC will be reversed
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The tank
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IVC collapsibility index
Collapsibility index : (Dmax-Dmin/Dmax)*100
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RAP and IVC collapse index
IVC diameter (cm) IVC collapse (%) Mean RAP (mmHg)
< 2.1 > 50% 0-5
>2.1 <50% 10-20
>2.1** >50% 5-10
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RAP and IVC collapse index
Advantage IVC dimensions are obtainable from the subcostal view
Disadvantage Not accurately in ventilator dependent patients
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MV-controlled ventilation
IVC distensibility index : (Dmax-Dmin/Dmin)*100
fluid responsiveness has distensibility index > 18%
IVC variability index: (Dmax-Dmin/Dmean)*100
fluid responsiveness has variability index > 12%
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The tank
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The tank
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The tank
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Fluid status assessment
IVC
Spontaneously breathing MV-controlled ventilation
IVC collapsibility IVC distensibility/variability
Preload/RAP Fluid responsiveness
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The tank
Leakage of the tank / Tank overload/Tank compromise
FAST
Lungs ultrasound
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The tank
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The tank
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“The Pipes”
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The pipes
Position ASuprasternal
Position B Parasternal Position C
Epigastrium
Position DSupraumbilicus
Position EFemoral DVT
Position F Popliteal DVT
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The pipes
Ruptered of the pipe Arterial systemAortic root < 3.8cm Parasternal long axis and Suprasternal view
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The pipes
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The pipes
AAA Short axis plane
outer wall to outer wall diameter exceed 3 cm
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The pipes
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The pipes
Obstruction of the pipe Thromboembolic eventIncomplete compression of the anterior and posterior walls of the vein
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The pipes
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The pipes
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The pipes
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The pipes
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The pipes
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“Thank you”