Post on 22-Jan-2020
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!WINFOCUS’ BASIC ECHO (WBE)
ECHOCARDIOGRAPHIC APPROACH FOR SHOCK
Achikam Oren-Grinberg, MD, MS
Assistant Professor in Anaesthesia Harvard Medical School
Director of Critical Care Echocardiography Department of Anesthesia
Critical Care and Pain Medicine Beth Israel Deaconess Medical Center
Boston
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!BASIC QUESTIONS
• Is it tamponade?
• Is it obvious LV or RV systolic dysfunction?
• Are there signs of pulmonary embolism?
• Is it empty or full?
• Is this septic shock?
• Am I full of air....?
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
TTE SUBCOSTAL/
APICAL
Pericardial effusion
Severely hypokinetic
LV
Severely enlarged
akinetic RV
Small hyperdynamic LV, collapsed
IVC
Hypercontractile LV
Tamponade Pump failure Pulmonary embolism
Hypovolemia Sepsis
No sliding sign Stratosphere
sign
Pneumothorax
ULTRASOUND SHOCK ALGORITHM
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
TTE SUBCOSTAL/
APICAL
Pericardial effusion
Severely hypokinetic
LV
Severely enlarged
akinetic RV
Small hyperdynamic LV, collapsed
IVC
Hypercontractile LV
Tamponade Pump failure Pulmonary embolism
Hypovolemia Sepsis
No sliding sign Stratosphere
sign
Pneumothorax
ULTRASOUND SHOCK ALGORITHM
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!PERICARDIAL EFFUSION
• Echo-free space surrounding the heart
• Small (<100 ml): posteriorly only
• Medium (100-500 ml): posterior, lateral, apical, anterior
• Large (>500 ml): > 2 cm circumferentially
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!PERICARDIAL EFFUSION
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!FINDINGS OF TAMPONADE
• Increased pericardial pressure ➔ chamber collapse
• Sequence of chamber collapse: - RA during systole (RA diastole!!) - RV during diastole - LA during systole (RA diastole!!) - LV during diastole (late)
• IVC Plethora
• Respiratory variation with transmitral flow
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!TAMPONADE
The concept to convey here is that with tachycardia` it is impossible to appreciate which chamber collapses in relation to the cardiac cycle. The solution is slowing down the clip or stopping altogether in order to appreciate the relationship between chamber collapse and cardiac cycle. !Note to speaker: it is possible to actually stop the clip during the presentation and move it manually to follow the chamber collapse in relation to the cardiac cycle
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!TAMPONADE
The concept to convey here is that with tachycardia` it is impossible to appreciate which chamber collapses in relation to the cardiac cycle. The solution is slowing down the clip or stopping altogether in order to appreciate the relationship between chamber collapse and cardiac cycle. !Note to speaker: it is possible to actually stop the clip during the presentation and move it manually to follow the chamber collapse in relation to the cardiac cycle
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!TAMPONADE
The concept to convey here is that with tachycardia` it is impossible to appreciate which chamber collapses in relation to the cardiac cycle. The solution is slowing down the clip or stopping altogether in order to appreciate the relationship between chamber collapse and cardiac cycle. !Note to speaker: it is possible to actually stop the clip during the presentation and move it manually to follow the chamber collapse in relation to the cardiac cycle
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!IVC PLETHORA
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!IVC PLETHORA
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!PERICARDIAL EFFUSION MEASUREMENT
The point to make in this slide is that measurement of the effusion should be of the largest pocket and in diastole.
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!TRANSMITRAL DOPPLER FLOW
This slide just reminds the students about how to obtain the transmitral inflow using pulse wave Doppler. This is just for a brief explanation of the technique. The next slide shows an actual measurement of transmitral inflow from a real patient with tamponade
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!TRANSMITRAL DOPPLER FLOW
This slide just reminds the students about how to obtain the transmitral inflow using pulse wave Doppler. This is just for a brief explanation of the technique. The next slide shows an actual measurement of transmitral inflow from a real patient with tamponade
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!TRANSMITRAL DOPPLER FLOW
This slide just reminds the students about how to obtain the transmitral inflow using pulse wave Doppler. This is just for a brief explanation of the technique. The next slide shows an actual measurement of transmitral inflow from a real patient with tamponade
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!TRANSMITRAL DOPPLER FLOW
MV: > 25%
The concept to convey in this slide is the significant variation with respiration. Important to re-emphasize the cut off of 25% change in the mitral valve inflow and 40% in the tricuspid inflow measurement.
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!THERAPY
• Pericardiocentesis
The message of this slide is the therapy of tamponade: pericardiocentesis. In this example, once the catheter is placed in the pericardium, saline is injected to verify catheter position before draining the effusion
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!THERAPY
• Pericardiocentesis
The message of this slide is the therapy of tamponade: pericardiocentesis. In this example, once the catheter is placed in the pericardium, saline is injected to verify catheter position before draining the effusion
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
TTE SUBCOSTAL/
APICAL
Pericardial effusion
Severely hypokinetic
LV
Severely enlarged
akinetic RV
Small hyperdynamic LV, collapsed
IVC
Hypercontractile LV
Tamponade Pump failure Pulmonary embolism
Hypovolemia Sepsis
No sliding sign Stratosphere
sign
Pneumothorax
ECHO SHOCK ALGORITHM
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
TTE SUBCOSTAL/
APICAL
Pericardial effusion
Severely hypokinetic
LV
Severely enlarged
akinetic RV
Small hyperdynamic LV, collapsed
IVC
Hypercontractile LV
Tamponade Pump failure Pulmonary embolism
Hypovolemia Sepsis
No sliding sign Stratosphere
sign
Pneumothorax
ECHO SHOCK ALGORITHM
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!APPROACH TO “PUMP FAILURE”
LV
RWMA
Global
Severity - Mild - Moderate - Severe
Size - Normal - Dilated
• Cardiomyophathy
The concept to emphasize in this slide is the approach to assessment of “pump failure”. In a very simplistic way, it is important to assess separately and sequentially the left and then the right ventricles for global and then regional wall motion abnormalities. !Both global and RWMA should then be qualified into the degree of severity. It is easy to divide them into three major groups -- mild, moderate or severe dysfunction
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!“PUMP FAILURE” CAUSES
• Cardiomyopathy
• Sepsis
• Ischemia/Acute coronary syndrome
• Myocarditis
• Cardiac contusion (RV)
This is just a partial list of causes of left ventricular systolic dysfunction.
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!ABNORMAL FUNCTION
• Qualitative assessment (eyeballing approach) - Using 2D modality
• Global vs. Regional wall motion abnormalities (Can have both!)
• Ejection fraction - Normal - Moderately depressed - Severely depressed
• Cardiac output calculation
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!NORMAL LV SYSTOLIC FUNCTION
In order to appreciate left ventricular systolic dysfunction one must first know what is normal function. Here is an example of four clips of normal left ventricular systolic function
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!NORMAL LV SYSTOLIC FUNCTION
In order to appreciate left ventricular systolic dysfunction one must first know what is normal function. Here is an example of four clips of normal left ventricular systolic function
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!GLOBAL HYPOKINESIS
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!GLOBAL HYPOKINESIS
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!RWMA: FOCAL AKINESIS
It is worth to emphasize that this is a grainy clip due to too much gain, but even with this suboptimal clip the apex is akinetic and even aneurysmal
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!RWMA: FOCAL AKINESIS
It is worth to emphasize that this is a grainy clip due to too much gain, but even with this suboptimal clip the apex is akinetic and even aneurysmal
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
TTE SUBCOSTAL/
APICAL
Pericardial effusion
Severely hypokinetic
LV
Severely enlarged
akinetic RV
Small hyperdynamic LV, collapsed
IVC
Hypercontractile LV
Tamponade Pump failure Pulmonary embolism
Hypovolemia Sepsis
No sliding sign Stratosphere
sign
Pneumothorax
ECHO SHOCK ALGORITHM
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
TTE SUBCOSTAL/
APICAL
Pericardial effusion
Severely hypokinetic
LV
Severely enlarged
akinetic RV
Small hyperdynamic LV, collapsed
IVC
Hypercontractile LV
Tamponade Pump failure Pulmonary embolism
Hypovolemia Sepsis
No sliding sign Stratosphere
sign
Pneumothorax
ECHO SHOCK ALGORITHM
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!APPROACH TO “PUMP FAILURE”
RVRWMA
Global
Severity - Mild - Moderate - Severe
Size - Normal - Dilated
• Mild • Moderate • Severe
The concept to emphasize in this slide is the approach to assessment of “pump failure”. In a very simplistic way, it is important to assess separately and sequentially the left and then the right ventricles for global and then regional wall motion abnormalities. !Both global and RWMA should then be qualified into the degree of severity. It is easy to divide them into three major groups -- mild, moderate or severe dysfunction
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!PULMONARY EMBOLISM
• Significant PE leading to hemodynamic instability will lead to signs of RV pressure overload - RV dilatation - RV free wall hypokinesis - Paradoxical septal movement (pressure overload)
• May see clot in transit (if lucky....)
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!NORMAL RV FUNCTION
RV#func(on#assessment#mostly#
qualita(ve#
RV#free#wall#mo(on#towards#
the#apex#
Look#for#thickening#
Look#at#Tricuspid#
annular#mo(on#
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!NORMAL RV FUNCTION
RV#func(on#assessment#mostly#
qualita(ve#
RV#free#wall#mo(on#towards#
the#apex#
Look#for#thickening#
Look#at#Tricuspid#
annular#mo(on#
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!NORMAL RV SIZE & FUNCTION
Normal RV/LV size: < 0.6 RV/LV = 1: mod RV dilatation
RV/LV > 1: significant RV dilatation
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!NORMAL RV SIZE & FUNCTION
Normal RV/LV size: < 0.6 RV/LV = 1: mod RV dilatation
RV/LV > 1: significant RV dilatation
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!NORMAL RV SIZE & FUNCTION
Normal RV/LV size: < 0.6 RV/LV = 1: mod RV dilatation
RV/LV > 1: significant RV dilatation
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!NORMAL RV SIZE & FUNCTION
Normal RV/LV size: < 0.6 RV/LV = 1: mod RV dilatation
RV/LV > 1: significant RV dilatation
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!ABNORMAL RV SIZE AND FUNCTION
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!ABNORMAL RV SIZE AND FUNCTION
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!ABNORMAL RV SIZE AND FUNCTION
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!McCONNELL’S SIGN
• Akinesia/hypokinesia of the mid-free wall
• Apical sparring (normal apical function)
• “Bye-bye sign”
• Original publication: 77% sensitive, 94% specific
• Not as specific as initially published
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!CLOT IN TRANSIT
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!CLOT IN TRANSIT
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!THERAPY
• Echo is NOT a diagnostic modality for pulmonary embolism
However.....
• With high pre-test probability and no access to CTA, can be used to guide diagnosis - Heparin - tPA - Surgical embolectomy - Catheter thrombectomy
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
TTE SUBCOSTAL/
APICAL
Pericardial effusion
Severely hypokinetic
LV
Severely enlarged
akinetic RV
Small hyperdynamic LV, collapsed
IVC
Hypercontractile LV
Tamponade Pump failure Pulmonary embolism
Hypovolemia Sepsis
No sliding sign Stratosphere
sign
Pneumothorax
ECHO SHOCK ALGORITHM
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
TTE SUBCOSTAL/
APICAL
Pericardial effusion
Severely hypokinetic
LV
Severely enlarged
akinetic RV
Small hyperdynamic LV, collapsed
IVC
Hypercontractile LV
Tamponade Pump failure Pulmonary embolism
Hypovolemia Sepsis
No sliding sign Stratosphere
sign
Pneumothorax
ECHO SHOCK ALGORITHM
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
2D clues of hypovolemic shock ‣ Small LV & RV diameter in systole and diastole ‣ Hypercontractile RV & LV ‣ Small and collapsing IVC
HYPOVOLEMIC SHOCK
The point to convey in this slide is that echo is not a good modality to assess fluid status. But it can be used to demonstrate hypovolemic shock -- basically when the “tank is empty”, the patient suffers from severe hypovolemic shock
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!2D SIGNS OF HYPOVOLEMIC SHOCK
This is an example of a patient who was in septic shock and a PAC used to assess hemodynamic demonstrated “bi-ventricular systolic dysfunction”: both CVP and PAOP were very high (> 20 mmHg). The team’s plan was to start inotropic support, however, an echocardiogram clearly demonstrated severe hypovolemia as seen in these clips. The other two clips show the same heart 24 hours after, and after appropriate fluid resuscitation. !The problem with the PAC was partially technical - it was placed in the left subclavian position and it appeared as if it was compressed by the clavicle.
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!2D SIGNS OF HYPOVOLEMIC SHOCK
This is an example of a patient who was in septic shock and a PAC used to assess hemodynamic demonstrated “bi-ventricular systolic dysfunction”: both CVP and PAOP were very high (> 20 mmHg). The team’s plan was to start inotropic support, however, an echocardiogram clearly demonstrated severe hypovolemia as seen in these clips. The other two clips show the same heart 24 hours after, and after appropriate fluid resuscitation. !The problem with the PAC was partially technical - it was placed in the left subclavian position and it appeared as if it was compressed by the clavicle.
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!2D SIGNS OF HYPOVOLEMIC SHOCK
This is an example of a patient who was in septic shock and a PAC used to assess hemodynamic demonstrated “bi-ventricular systolic dysfunction”: both CVP and PAOP were very high (> 20 mmHg). The team’s plan was to start inotropic support, however, an echocardiogram clearly demonstrated severe hypovolemia as seen in these clips. The other two clips show the same heart 24 hours after, and after appropriate fluid resuscitation. !The problem with the PAC was partially technical - it was placed in the left subclavian position and it appeared as if it was compressed by the clavicle.
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!THERAPY
Therapy is easy once the diagnosis is made - either aggressive fluid therapy or blood depending on the etiology
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
TTE SUBCOSTAL/
APICAL
Pericardial effusion
Severely hypokinetic
LV
Severely enlarged
akinetic RV
Small hyperdynamic LV, collapsed
IVC
Hypercontractile LV
Tamponade Pump failure Pulmonary embolism
Hypovolemia Sepsis
No sliding sign Stratosphere
sign
Pneumothorax
ECHO SHOCK ALGORITHM
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
TTE SUBCOSTAL/
APICAL
Pericardial effusion
Severely hypokinetic
LV
Severely enlarged
akinetic RV
Small hyperdynamic LV, collapsed
IVC
Hypercontractile LV
Tamponade Pump failure Pulmonary embolism
Hypovolemia Sepsis
No sliding sign Stratosphere
sign
Pneumothorax
ECHO SHOCK ALGORITHM
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!MANIFESTATION OF SEPTIC SHOCK
• Hypercontractile state (hyperdynamic)
• Hypocontractile state (“pump failure”) - Global LV (and sometimes RV) hypokinesis
!
!
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!MANIFESTATION OF SEPTIC SHOCK
• Hypercontractile state (hyperdynamic)
• Hypocontractile state (“pump failure”) - Global LV (and sometimes RV) hypokinesis
!
!Hyperdynamic ➙ Hypodynamic
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!LV DYSFUNCTION IN SEPSIS
This is an example of a patient in septic shock and septic cardiomyopathy, which resolved after the resolution of sepsis
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!LV DYSFUNCTION IN SEPSIS
This is an example of a patient in septic shock and septic cardiomyopathy, which resolved after the resolution of sepsis
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
HYPOVOLEMIA
Low ESA
Low ESA
Low EDA
Normal EDA
VASODILATION
HYPOVOLEMIA VS. VASODILATATION
This slide explains the difference between severe hypovolemia and vasodilatory shock. While in both cases end-systolic area will be small, in vasodilatory state end-diastolic area will be either normal or only slightly reduced. In hypovolemic shock end-diastolic area will be much reduced.
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
HYPOVOLEMIA
Low ESA
Low ESA
Low EDA
Normal EDA
VASODILATION
HYPOVOLEMIA VS. VASODILATATION
This slide explains the difference between severe hypovolemia and vasodilatory shock. While in both cases end-systolic area will be small, in vasodilatory state end-diastolic area will be either normal or only slightly reduced. In hypovolemic shock end-diastolic area will be much reduced.
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
TTE SUBCOSTAL/
APICAL
Pericardial effusion
Severely hypokinetic
LV
Severely enlarged
akinetic RV
Small hyperdynamic LV, collapsed
IVC
Hypercontractile LV
Tamponade Pump failure Pulmonary embolism
Hypovolemia Sepsis
No sliding sign Stratosphere
sign
Pneumothorax
ECHO SHOCK ALGORITHM
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
TTE SUBCOSTAL/
APICAL
Pericardial effusion
Severely hypokinetic
LV
Severely enlarged
akinetic RV
Small hyperdynamic LV, collapsed
IVC
Hypercontractile LV
Tamponade Pump failure Pulmonary embolism
Hypovolemia Sepsis
No sliding sign Stratosphere
sign
Pneumothorax
ECHO SHOCK ALGORITHM
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!PNEUMOTHORAX
• Change to high frequency probe
• Interrogate bilateral anterior intercostal spaces
• Interrogate all spaces, not just one
• Look for lung sliding sign (live 2D mode)
• Verify with M-mode - Stratosphere sign (bar code sign): Normal - Seashore sign: Abnormal (± pneumothorax)
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!
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!LUNG POINT
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!LUNG POINT
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!LUNG POINT
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!THERAPY
Therapy is easy once the diagnosis is made....
© WINFOCUS’ CRITICAL CARE ECHOCARDIOGRAPHY
!
TTE SUBCOSTAL/
APICAL
Pericardial effusion
Severely hypokinetic
LV
Severely enlarged
akinetic RV
Small hyperdynamic LV, collapsed
IVC
Hypercontractile LV
Tamponade Pump failure Pulmonary embolism
Hypovolemia Sepsis
No sliding sign Stratosphere
sign
Pneumothorax
ECHO SHOCK ALGORITHM