Ultrasound in undifferentiated shock
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Transcript of Ultrasound in undifferentiated shock
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Ultrasound in Undifferentiated Shock
Dr James Wheeler BSC (Hons) MBBS FACEM DDU (General)
Emergency Physician SCGH
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What we will cover• What is point of care ultrasound
� SCGH ED US Service
• Shock� Definitions / Causes / Treatments
• How US may be used to investigate a patient with undifferentiated shock� Some ultrasound protocols� Limitations of US examination� Some examples of sonographic findings in particular causes of shock
• What we won’t cover:� How to perform an ultrasound� Detailed interpretation of ultrasound
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Point of Care / Bedside Ultrasound• Use of US at the patients bedside to answer
specific clinical questions and assist in clinical diagnosis and management � Also help guide certain procedural treatments
(IV access, pericardiocentesis etc…)
• Advantages:� Bedside (no transfer out of dept.)� Can be accessed immediately� Nil radiation� Functional imaging (CO, PAP...)� Assessment can be adapted to fit clinical
assessment & sonographic findings
• Limitations:� Training / experience and operator dependent� Sometimes difficult to obtain certain views
(sonographic windows) in critically unwell / unprepared patients
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SCGH ED US Service• Established 2005
• Internationally regarded (thanks to Ass Prof James Rippey)
• 6 DDU FACEM’s (General and Emergency), 1 Fellow, 1 Registrar� DDU = 2 years supervised US training, primary and secondary exams� One consultant rostered for EDUS 0800-1800 weekdays (afterhours as per our
rostering)
• Skills of US examination are now becoming an essential part of critical care training� Other members of the ED, and other critical care, staff have varying levels of
training and experience in critical care and procedural ultrasound
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SCGH ED Service: What do we do?Diagnostic Procedural Critical Care
• Abdominal • Reproductive systems• Vascular (some)• Musculo-skeletal (some)• Cardiac• Lung• Ocular• Masses
• Vascular access (PVC, CVC, arterial)
• Effusion drainage (joint, pleural, pericardial, ascitic)
• Abscess drainage• Nerve blocks• Foreign body removal
• Cardiac arrest• Major trauma (EFAST)• Chest pain• Collapse• Shortness of breath• Sepsis (?source ?fluids
or inotropes)• Pregnancy related
abdominal pain• Undifferentiated shock
…and Education / Teaching!
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Shock• Hypotension Defn:
� SBP < 90mmHg� Shock Index (HR/SBP) probably better indicator of potential shock (N 0.5-0.8, SI > 1 ?Shock)
• Shock Defn:� Life–threatening condition of circulatory failure resulting in inadequate tissue
perfusion, cellular hypoxia and END ORGAN DYSFUNCTION (confusion, renal failure, hepatic failure….)
• Undifferentiated Shock:� Shock is recognised, but the cause is unclear
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Undifferentiated shock• Relatively common in ED
• Important predictor of mortality
• Different subtypes of shock require different management (that may be life-saving if done in a timely fashion)
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Shock – CausesCause ExampleHypovolaemia Haemorrhage (trauma, AAA, ectopic)
GI Loss (gastroenteritis)Renal Loss (DKA)Reduced intake
Cardiogenic AMICardiomyopathyValvular failureVentricular aneurysm / rupture
Obstructive Tension PTXTamponadeMassive PEHCMAtrial myxoma
Distributive SepsisAnaphylaxisNeurogenicToxicological
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Evidence – US in Shock• Overall very good agreement (90 – 100%) between the US diagnosis (~20mins post
arrival) and final diagnosis (k = 0.71 – 0.9) 1, 2, 3
• Changes in Mx:� Decreases physician diagnostic uncertainty� Increased patients with transferred from ED with a definitive diagnosis � 24.6% of patients had a significant change in the use of IV fluids, vasoactive agents, or
blood products. 2� Major diagnostic imaging (30.5%), consultation (13.6%), and emergency department
disposition (11.9%) 2
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Patients evaluated with POCUS had less time on vasopressors and showed trends toward fewer days in the ICU and decreased morbidity
• Unpublished
• April 2016
• 45 patients (22 had US, 23 did not) in ICU (Portland USA)
• Assessed fluid responsiveness (resp change in IVC diameter, LVOT VTI after SLR)
• Results:� 38% reduction in time on vasopressor (p = 0.038)� Trends to reduction in hours on ventilators and
days in ICU (see next slide)� Calculated savings of ~$20,000 / patient
Impact of POCUS on therapyPOCUS group
Control group p-value
Total hours on vasopressors
36.43 58.57 0.038
Hours to 50% wean off vasopressors
22.24 40.66 0.0952
Total hours on ventilator 68.3 133.67 0.283Days in ICU 4.41 6.67 0.2
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US in Undifferentiated Shock• Many different target-directed US exams developed to determine cause/s of
shock
• At SCGH ED often tailored / focused US examination to answer clinical questions relevant to the clinical assessment of the patient
• Note: US also useful in guiding treatment procedures and monitoring response to treatment in this patient group
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US Protocols for Shock Assessment:The image part with relationship ID rId2 was not found in the file.
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Rapid Ultrasound in Shock (RUSH)
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Rapid Ultrasound in Shock (RUSH)The image part with relationship ID rId2 was not found in the file.
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BestViews
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Rapid Ultrasound in Shock (RUSH)The image part with relationship ID rId2 was not found in the file.
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Rapid Ultrasound in Shock (RUSH)The image part with relationship ID rId2 was not found in the file.
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Hypovalaemia Shock
• Haemorrhage – Ruptured AAA / Ectopic Pregnancy / Solid organ injury / Thoracic injury• GI Loss – Gastroenteritis• Renal loss – DKA• Reduced Intake
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Hypovolaemia - IVC Collapse / Variability
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Hypovolaemia - IVC Collapse / Variability
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Hypovalemia - IP Free Fluid / Haemorrhage
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Hypovalemia - IP Free Fluid / Haemorrhage
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Hypovolaemia – Ruptured Ectopic Pregnancy
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Hypovolaemia – AAA (?signs of rupture)
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Hypovolaemia – AAA (?signs of rupture)
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Aortic Dissection
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Aortic Dissection
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Cardiogenic Shock
• AMI• Acute valvular dysfunction• Ventricular aneurysm• Cardiac rupture• Cardiomyopathy (acute or chronic)
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Cardiogenic – LV Contractility
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Cardiogenic – LV Contractility
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Cardiogenic - AMI – RWM AbN
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Cardiogenic - AMI – RWM AbN
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Cardiogenic – Pulmonary Oedema
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Cardiogenic - APO & Pleural Effusions
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Cardiogenic - APO & Pleural Effusions
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Obstructive Shock
• Massive or Sub-Massive PE• Cardiac Tamponade• Tension PTX
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Obstructive – PE
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Obstructive – PE - RV Dilatation
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Obstructive – PE - RV Dilatation
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Obstructive – PE - RV Dilatation / Contractility
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Obstructive – PE - RV Dilatation / Contractility
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Obstructive – PE / Tamponade:IVC Fixed Distension
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DVT
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Obstructive – Pericardial Tamponade (Subcostal)
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Obstructive – Pericardial Tamponade (PLX)
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Obstructive – Pericardial Effusion (PLX)
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Obstructive – ??Pericardial Effusion
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Obstructive - ?Tension Pneumothorax
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Lung Contact Point
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Thoracic Aortic Aneurysm with Tamponade
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Distributive Shock
• Sepsis (?source)• Anaphylaxis• High Spinal Injury• Toxicological Vasoplegia
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Distributive – Intraperitoneal Gas & Fluid
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Distributive – ?Sepsis Source
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References:
1. Ghane et al. Accuracy of Rapid Ultrasound in Shock (RUSH) Exam for Diagnosis of Shock in Critically Ill Patients. J Emerg Trauma Shock. 2015 Jan-Mar;8(1):5-10.
2. Shokoohi et al. Bedside Ultrasound Reduces Diagnostic Uncertainty and Guides Resuscitation in Patients With Undifferentiated Hypotension. Crit Care Med. 2015 Dec;43(12):2562-9
3. Volpicelli et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med (2013) 39:1290–1298