2/16/2014 ED Ultrasound for Undifferentiated Hypotension Nate - - PDF document

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ED Ultrasound for Undifferentiated Hypotension

Nate Teismann MD Director of Emergency Ultrasound Emergency Ultrasound Fellowship Director Dept of Emergency Medicine, UCSF nathan.teismann@ucsf.edu

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70 F “not feeling well” + syncope

• PMH: Unknown
• Meds: Unknown
• Pale, Diaphoretic
• Afebrile, Faint crackles,

tachypneic, otherwise unremarkable exam

BP = 62/38 Why is this patient sick? Your approach with US:

• Heart:
• Is there an effusion/tamponade?
• What is the LV doing?
• Is the RV under strain?
• IVC:
• What is the CVP?
• Lungs, Deep LE Veins, Aorta:
• Is there a pneumothorax, pulmonary edema, or lower lobe PNA?
• Is there a DVT or Aortic Pathology?

80% sepsis or hypovolemia Can’t I just try a fluid challenge?

• Fluid therapy is mainstay of treatment...except when it’s not.
• Other interventions:
• Pressors/Inotropes?
• ED procedures (pericardiocentesis, thoracostomy)?
• To OR?

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QuickTime™ and a VC Coding

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Step 1: What is the heart doing?

• Is there an effusion present?
• If so, are there signs of tamponade?
• Clinical > US findings!

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Step 1: What is the heart doing?

• Is there an effusion present?
• If so, are there signs of tamponade?
• LV size and systolic function
• Normal, Poor, Hyperdynamic
• EPSS

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EPSS > 1cm predicts EF < 50% Mitral E-Point Septal Separation Step 1: What is the heart doing?

• Is there an effusion present?
• If so, are there signs of tamponade?
• LV size and systolic function
• Normal, Poor, Hyperdynamic
• EPSS

Step 1: What is the heart doing?

• Is there an effusion present?
• If so, are there signs of tamponade?
• LV size and systolic function
• Normal, Poor, Hyperdynamic
• EPSS
• RV size and function

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Size: Normal RV < 70% LV LV RV

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RV LV Signs of acutely elevated R-sided pressures:

• 1) RV enlargement
• 2) RV hypokinesis (possibly with apical sparing = McConnell’s)
• 3) Flattening of the interventricular septum (D-shaped LV)
• 4) RA and IVC dilation

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Acute!

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Chronic

1) Mild-Mod RV Enlargement 2) No RVH 3) McConnell’s Yes 1) Severe RV Enlargement 2) RVH 3) McConnell’s No

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Thrombus “In-Transit” Step 1: What is the heart doing?

• Is there an effusion present?
• If so, are there signs of tamponade?
• LV size and systolic function
• Normal, Poor, Hyperdynamic
• EPSS
• RV size and function
• Signs of elevated R-sided pressures?
• VERY large RV with RVH suggests chronic pulmonary HTN

Step 2: What is the CVP?

• Look at IVC: 2 parameters
• 1) Maximum diameter
• 2) Caval Index (% collapsibility with inspiration)

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Normal

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CVP High CVP Low Step 2: What is the CVP?

• Look at IVC: 2 parameters
• 1) Maximum diameter at hepatic vein inlet
• > 2cm suggests CVP >10
• 2) Caval Index (% collapsibility with inspiration)
• > 50% collapse with passive inspiration predicts CVP < 8

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Normal

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CVP Low

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CVP High Step 2: What is the CVP?

• Look at IVC: 2 parameters
• 1) Maximum diameter
• > 2cm suggests CVP >10
• 2) Caval Index (% collapsibility with inspiration)
• > 50% collapse with passive inspiration predicts CVP < 8
• Big, dilated, noncollapsible IVC = CVP high
• Small, thin, highly collapsible IVC = CVP low

Step 3a: Anything in the lungs?

• Is there a pneumothorax?
• Is there a consolidation?
• Are there B lines?

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Step 3b: Anything elsewhere?

• Is there a blood in the abdomen?
• Is there a AAA?
• Are there a DVT?

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Review

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CHF, cardiogenic shock

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PNA, Sepsis, hypovolemia

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Pericardial Effusion with Impending Tamponade

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Acute Massive PE

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Thanks!