Rapid Ultrasound in Shock

RobertKollpainter,PA-C,FAPACVS,RDMS,CAQinCVTSAspirusHeart&LungSurgery

AspirusHeart&VascularInstituteWausau,Wisconsin

Rapid Ultrasound in Shock

• Point-of-CareUltrasound• Allowsforrapidevaluationofreversiblecausesofshock• Improvesaccuratediagnosisinundifferentiated

hypotension.• Earlyrecognitionandappropriatetreatmentofshockhasbeen

showntodecreasemortality.

P-T-P

P-T-P

P-T-P

Pump-Tank-Pipe

Pump

American Society of Echocardiography/ American College of Emergency Physicians

Consensus Statement

“the ability to assess global left ventricular function, to detect pericardial effusions, and to assess for right heart

dilatation (chamber sizes) are within the scope of clinicians and can help answer critical patient

management questions.”

Pump - Views• ParasternalLong(PLAX)• ParasternalShort(PSAX)• Apical4Chamber(A4CH)• Subxyphoid(SUBX)

Pump

• Phasedarrayprobe• Cardiacsetting

– Setsindicatorsoppositetogeneralsettings– Fasterframerate– Accesscalculationspackages

• IndicatortowardsRshoulder• 2-3rdICSattheedgeoftheLsternum,scancaudally

Pump - Parasternal Long (PLAX)

Pump - Parasternal Short (PSAX)• FromPLAX,rotate90°clockwise

Pump - Apical 4 Chamber (A4CH)

• Indicatorat2-3o’clock• Mid-clavicularline,Inframammarycrease

Pump - Subxyphoid (SUBX)• Indicatorat3o’clock• Overhandgrip

Pump - Questions

• IsthereaPericardialEffusion?• WhatdoestheLeftVentricularContractilitylooklike?• HowdoestheRightVentricularSizelook?

Is there a Pericardial Effusion?

• Smalleffusionwillappearasadarkstripearoundtheheart• Largeeffusionwillcircumferentiallysurroundtheheart• Maybeloculatedinpost-operativeorpost-traumaticpatients

– Bloodclottingstartsanechoic,becomesechogenic,thanbecomesanechoicagain

Pericardial Effusion

Pericardial Effusion vs. Tamponade

–Maybeacuteorchronicanddependsontheamountoffluidandrateofaccumulation– 50-100ccmaycausetamponadeifitaccumulatesrapidlyenough

– Inthefaceofhypotensionassumetamponadeuntilprovenotherwise

Cardiac Tamponade

• Tamponadephysiologyoccursifthepressureinthepericardialsacexceedstherightatrialorventricularenddiastolicfillingpressures

• Ifthisoccurs,thecardiacchambersareunabletofill• Ultrasoundfindings:– Pericardialeffusion– Rightatrialsystoliccollapse– Rightventriculardiastoliccollapse– PlethoricIVC(>2cm)

Cardiac Tamponade

The Curse of CV Surgery

Transthoracicechocardiographywillfailtoprovideadequatevisualizationofanypericardialcollectionsinthecardiac

surgerypatientsduetounsatisfactoryacousticwindowsinupto60%ofpatientswithinthefirst72hours.

Theechocardiographicfeaturesofclassical‘tamponade’werenearlyalwaysabsent.

PriceS,etal,EurJCardiothoracSurg2004;26:1156–60.

Pump- LV Function

Hyperdynamic(EF>70%)Normal(EF55-70%)

Moderatedysfunction(EF30-55%)Severedysfunction(EF<30%)

Pump- LV Function

Pump- LV Function

E/A Ratio

Pump- LV Function

• E-pointSeptalSeparation(EPSS)• ParasternallongwithM-modeattipofanteriormitralvalve• EPSS<7mmisnormal• >1cm=lowEF

Pump- LV Function

Pump - RV

• NormalLVtoRVratio=1:0.6• IncreasedratioinahypotensivepatientsuggestsPE

– flatteningoftheinterventricularseptumintotheLVduringdiastole

• IfRVwallthickened,maybeindicativeofRVhypertrophyduetochronicPAhypertension

LV:RV Ratio

1.00.6

That’s the Pump…

Tank

Tank - Views

• SubcostalIVC– Indicatortowardsheadjusttotheleftofmidline– mustviewhepaticvein

• eFAST

Tank - Questions

• Isthetankfull?• Isthetankleaky?• Isthetankcompromised?

Tank - Fullness

• IVC• Transversevs.long• Evaluate2cmbelowjunction• Sonospirometry

– IVCsizevariationduringinspiration

IVCDiameter Sniff CVP ShockType

<2.0cm >50% 0-5mmHg Hypovolemic/Distributive

5-10mmHg

>2.0cm <50% 10-20mmHg Cardiogenic/Obstructive

“Tank Fullness” does not equate to

“Pump Responsiveness”

Tank- Fullness Made Easy

• <1cm-givevolume• >2cm-don’tgivevolume• >1cm-<2cm-Judgementcall

Tank - Leakiness

• Traumaticpatients– Lookingforaholeinthetank

• Non-traumaticpatients– Lookingfor“tankoverload”

• Pulmonaryedema• Pleuraleffusions• Ascites

Tank - Compromise

• Pneumothorax– Tension

That’s the Tank

Pipes

Pipe - Questions

• Istherearupturedpipe?– Aorticaneurysm– Aorticdissection

• Isthereanobstructedpipe?– DeepvenousThrombosis

Pipe - Views

• Transverseabdominalaorta• Suprasternal• Parasternallong• Groin/Poplitealfossa

Pipe - AAA

• AbdominalAortaAneurysm– >3cm=diagnosis– AAA>5.5cm=surgery– Mortalityrate90%ifoccursoutofhospital– RuptureconsidereddifficultforultrasoundasAAArupturesintothe

retroperitoneum

Pipe - Dissection

• Parasternallong– SuggestionifAorootdilatedandintimalflap

• NlAoroot<3.8cm

– MayseeAIorpericardialeffusion

• Suprasternal

Pipe - DVT

Rig

ht

Vas

cula

r Sy

stem

Rig

ht

Vas

cula

r Sy

stem

Rule-Out DVT

TheSimplifiedCompressionTechnique

Doesthecommonfemoralveinfullycompress?Doesthepoplitealveinfullycompress?

Clot Location

Popliteal10%

Pop-SFV42%

Pop,SFV,CFV5%

AllProxVeins35%

CFV±SFV8%

HemostasisandThrombosis:BasicPrinciples.3rded.,pp1305

Rule-Out DVTThe Technique

Rule-Out DVTFinal Thoughts

• Whataboutbelowtheknee?– Examinationverytimeconsuming– Mostvascularlaboratoriesnolongerscanbelowthepoplitealspace– Successratesaslowas40%inexperiencedhands– Repeatexamin5-7daysisrecommendedintheemergencyroom

setting

One Approach…

Shock: Name One Thing That Defines…

• Hypotension

The Weil’s Classification

• Obstructive• Cardiogenic• Hypovolemic• Distributive

The Weil’s Classification

• Obstructive– Tamponade– PulmonaryEmbolism– TensionPneumothorax

• Cardiogenic• Hypovolemic• Distributive

– Sepsis– VasoplegicSyndrome

The Weil’s Classification

• Obstructive– Pericardium– RightHeart– Lungslide

• Cardiogenic– B-Lines– LVFxn

• Hypovolemic– LVFxn

• Distributive

Fluid Administration Limited by Lung Sonography

Based on 8 considerations

1.Acirculatoryfailureisadeadlycondition2. Thereisanabsenceofgoldstandardforafastassessment3. Thetoolsformeasuringvolumestatusareratherindirect.4. TheFALLS-protocolconsiderstheweakestpumpastheleftventricleandwillmanifestashemodynamicpulmonaryedema(HPE)

5. InterstitialedemaalwaysprecedesalveolaredemawhenaHPEoccurs6. Alveolarvolumeissubstantialandaninterstitialvolumeisverysmall7. TheB-lineallowsfirstanqualitativediagnosisofpulmonaryedemaandgeneratedonanon-offbasis

8. Atapulmonaryarteryocclusionpressure(PAOP)ofa18-mm-Hg,A-linesarereplacedbyB-lines

The FALLS Protocol

RuleoutObstructiveshock

RuleoutCardiogenicshock

TamponadePulmonaryEmbolismPneumothorax

RuleoutHypovolemicshock(GiveVolume)

B-profile

Improvement

Noimprovements

SepticShock

HypovolemicShock

Let’s Scan!

• Pump• ParasternalLong(PLAX)• ParasternalShort(PSAX)• Apical4Chamber(A4CH)• Subxyphoid(SUBX)

• Tank– IVC– eFAST

• Pipes– DVT