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LV function

1. Normal

2. Abnormal3. Unsure

Estimation of CVP

Estimated CVP

IVC diameter(mm)

% collapse EstimatedCVP (mm

H 2 0)

< 20 > 50 5

< 20 < 50 10

> 20 < 50 15

> 20 0 20

Management

Fluid resuscitationIV antibioticsPelvic examinationClinical diagnosis toxic shock syndromeWhy was she not tachycardic?

IVC m-mode Be careful with M-mode of IVC

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Underfilled IVC Distended IVC with no collapse

Caution

Small studies of specific cohorts to predictresponse to fluid, or PACWPSome patients ventilated, others notSome with known cardiac failurePart of overall clinical assessment

Case

54 yrs, maleDyspnoea and cough for one weekInitially thought viral, attended GP whoprescribed antibioticsSudden deterioration at homeWife described dyspnoea, wheeze and then

collapseNo past medical history

Examination

Unconscious male, GCS 7SaO2 81% (15 litres)BP 88/30, p 118/min (sinus)HS normalChest bilateral reduced air entry, expwheezeIntubated, remained hypotensive

Focused echo A4ch

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PSAX IVC view

Echo assessment of fluidstatus1. Underfilled give IV fluid challenge2. Euvolaemic3. Overloaded not for IV fluids4. Unsure

Management

Aggressive fluid resuscitationWife arrived after ambulanceBrought prescription from GP amoxycillinPrevious rash with penicillinTreated with adrenaline, hydrocortisone,piriton

Dx - Life threatening anaphylactic reaction topenicillin (confirmed by IgE reactivity)

Case

74 yrs, malePost-op left hemicolectomy (completeresection of Duke A colonic carcinoma)PMH- hypothyroidism (on thyroxine) andangina (well controlled)No anaesthetic complicationsJust arrived in HDU for post-op careSudden onset chest pain, dyspnoea thencirculatory collapse

Examination

Distressed and agitated, GCS 14SaO2 97% (28% O2, 4 l/min)BP 74/30 (arterial line)HR 107/min, sinusChest clearHS normalAbdomen laparotomy scar

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Focused echo, A4ch PLAX

A2Ch Management

1. Aggressive IV fluids2. IV diuretics3. Inotropes4. Back to theatre for exploratory laparotomy5. Unsure

Management

Central line examined3 way connector incompletely attachedDiagnosis- air embolismManagement- line sealed, fluid resuscitation,high flow O2

Case

71 yrs, femaleCough, pleuritic chest pain, rigorsBackground COPD, diabetes, renalimpairment (eGFR 25), hypertensionHuge list of medication (including enalapril,doxasosin, bendrofluazide, aspirin, inhalers,metformin)Started on augmentin and steroids 48 hrs ago

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Examination

Unwell, GCS 15

SaO2 91% (28%, 4 l/min)BP 80/48P93/min (sinus)HS normalChest poor air entry bilaterally, scatteredwheeze and bibasal cracklesAbdo normal

Focused echo

IVC view Based on this limitedassessment1. For fluid challenge2. Not for fluid challenge3. Unsure

Management

Not given IV fluidsCXR confirmed upper lobe diversion andbibasal consolidationAntihypertensives witheld24 hrs of noradrenaline to maintain BPBroad spectrum IV antibioticsGood clinical progress

Case

65 yrs, maleChest pain, dyspnoeaTook his wifes GTN spray and collapsed Ambulance calledPMH- hypertensionRx- lisinopril and aspirin

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Examination

Pale, clammy, GCS 15

SaO2 96% (air)BP 76/30P124/min (sinus)HS quietChest clearAbdo normal

Focused echo, PLAX A4Ch

PSAX PSAX

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Management

1. Presumed GTN syncope reassure and

discharge if troponin negative2. Fluid challenge3. Inotropes4. Cardiac surgery5. Unsure

Management

Presumed GTN syncope

Background antihypertensivesECG suggested LV hypertrophyClinically undiagnosed aortic stenosisFormal echo confirmed critical calcific aorticstenosisNormal coronary arteriesSuccessful aortic valve replacement

Case

27 yrs, maleRugby playerDay case arthroscopySudden hypotension in recovery roomNo medical historyNot registered with GP

Examination

GCS 11/15 (10 mins post-op)SaO2 99% (35% o2)P80/min, sinusBP 78/42HS I + II + soft ESMChest clear

Focused echo, PLAX PSAX

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A4ch Colour

Likely management

1. Anaphylaxis, for IV fluids, IM adrenaline2. Dehydrated, for IV fluids3. Pulmonary embolism, for thrombolysis4. Internal cardiac defibrillator5. Unsure

Management

HOCM diagnosed by echoCautious fluid resuscitationIV esmolol infusionFamily screening & genetic analysis24hr tape to risk assess VT identifiedICD implanted, blocker started

Has had to stop playing rugby

Case

24 yrs male, joyriderLost control of car at around 80 mph, dualcarriagewayHead on collision with HGVExtracted by fire serviceNot wearing seat belt, air bag deployedSerious head injuries, bilateral humeral shaftfracturesLikely blunt chest trauma

Progress

Aggressive fluid resuscitation, transfusionSkeletal survey- no sternal fractureFractures stabilisedCT bilateral occipital lobe contusion, smallfrontal haematoma, no cervical spine fractureTransferred to ITU for ventilation and post-opcare

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Progress

Frequent ventricular ectopics

Normal urea & electrolytesBP initially 110/64, drifting despite IV fluidand now noradrenaline

A4ch

PLAX Diagnosis

1. Trivial pericardial fluid likely contusion2. Clinically significant pericardial effusion3. Pulmonary embolism secondary to trauma4. Unsure

Management

CT thorax confirmed partial pulmonarytransection with leak of contrast intopericardiumContinual transfusion requirementUnstable transfer for cardiac surgerySuccessful repair of pulmonary rootEventual transfer to definitive rehab facility

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Case

33 yrs, female

Sudden onset dyspnoea, palpitationsBackground of exertional dyspnoeaTreated with inhalers but no improvementNo siblings was adopted after mother diedage 29 yrs (about six months post delivery)No other medical history

Examination

Pale, dyspnoeic, GCS 15

SaO2 91% (15 litres)BP 78/47P190/minChest bibasal and mid zone cracklesHS fast

Management

DC shock with low dose propofol200J VF200J VF360J sinus tachycardia (129/ min)

Focused echo A4Ch

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A4Ch (subsequent echo with contrast) Management

Initially stabilised with MgSo4 infusion

Further VT, started on IV amiodaroneAngiography normalCardiac MRI confirmed echo appearancesNon-compaction syndromeOn cardiac transplant waiting listICD implanted, anticoagulatedGenetic markers

Non-compaction example, PSAX