ACTEP2014: Hemodynamic US in critical care
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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%