ACTEP2014: Hemodynamic US in critical care

Hemodynamic ultrasound in critical care

Suthaporn Lumlertgul M.D.!Emergency unit, King Chulalongkorn Hospital!

WINFOCUS Thailand director

Circulatory failure

Persistent shock despite initial therapy Main Mechanism of shock

Complicated AMIRWMA, LV dysfunction, RV involvement, mechanical

complication

Complicated acute coronary syndrome

Tamponade, acute aortic regurgitation, LV dysfunction

Massive Pulmonary Embolism Acute corpulmonale

Cardiac tamponade Circumferential compressive pericardial effusion

RUSH - every organ except Gyne POCUS - every organ except lung effusion

FEEL- Heart FATE - Heart+ Pleural effusion

shock

Hypovolemic Distributive Cardiogenic Obstructive

Collapsed IVC Large IVC

Small hyperdynamic LV Hypodynamic LV Tamponade

PE

Tension PNX

CHF

Effusion(Pericardial)

Ejection fraction EYEBALL, EPSS

Equality(Pulmonary embolism)

Effusion(Pericardial)

Ejection fraction EYEBALL, EPSS

Equality(Pulmonary embolism)

Circumferential

compressive

pericardial effusion

https://web.stanford.edu/group/ccm_echocardio/cgi-bin/mediawiki/index.php/Tamponade

https://web.stanford.edu/group/ccm_echocardio/cgi-bin/mediawiki/index.php/Tamponade

Tamponade

RVIVS

PWMV

PE

collapse of the RV during diastole.

normal M mode from http://

ventricular

RIV

PM

P

}diastol

X X

RV

MV

Effusion(Pericardial)

Ejection fraction EYEBALL, EPSS

Equality(Pulmonary embolism)

LV Function

• Global hypokinesis = reduced EF

• Do not need a number

• Normal (>50%)

• Decreased (30-50%)

• Severely decreased (<30%)

• Things to look for

• Wall movement--change in ventricular area

• Wall thickening

• MV anterior valve movement (2-7 mm normal)

Weekes AJ, Zapata RJ, Napolitano A. Symptomatic Hypotension: ED Stabilization and the Emerging Role of Sonography. Emergency Medicine Practice. Nov 2007, Vol. 9, No. 11.

Compare eyeball(3 grade) to actual measure

LV Function--Sepsis

Inward motion of the endocardium

Thickening of the myocardium

Longitudinal motion of the mitral annulus

Geometry of the ventricle

End Point Septal Seperation

End Point Septal Seperation

RV Dysfunction

RV Dysfunction

• Other signs of PE

• Septal flattening / LV imprairment

• McConnell sign

• PA pressures

• Tricuspid Regurgitation

• Right atrial enlargement

Volume responsive assessment tools

Volume independent

First Diagnosis

รับ refer, load มาแล้วสักพัก

use CVP, RV, LV size, PAOP

Clinically suspected hypovolemia fluid-responsiveness approach

Mechanically ventilated patient Spontaneous breathing patient

Passive leg raising

Mechanically ventilated patient

TTE

Sinus rhythm Arrhythmia

Passive leg raising Distensibility IVC

Aortic blood flow

Lamia et al. demonstrated in 24 patients that PLR induced an increase in SV of 12.5% or more predicted an increase in SV of 15% or more after volume expansion with a sensitivity of 77% and a specificity of 100%