Disclosures Undifferentiated Hypotension I have no relevant - PDF document

3/22/2016 Disclosures Undifferentiated Hypotension • I have no relevant financial relationships to discloseI will not discuss any off-label use and/or investigational use in my Aparajita Sohoni MD presentation Alameda Health System - Highland Hospital April 7, 2016 US Protocols for Shock • *Thanks to Arun Nagdev MD for use of slides/videos in preparation of this talk. 1

3/22/2016 Outline RUSH • What? • Why? • R apid U ltrasound for S hock and • When? H ypotension • How? • Cases What is the RUSH HIMAP exam? • H eart • Rapid, systematic evaluation of: • I VC - heart (pump) • M orison’s/FAST - effective intravascular status (tank) • A orta - arterial/venous circulation (pipes) • P neumothorax 2

3/22/2016 Why do we do it? Types of Shock • Hypovolemic • Assess etiology of shock • Cardiogenic • Reversible causes of shock • Obstructive • Guide resuscitation • Distributive When? • Unexplained hypotension or shock • Part of the primary resuscitation 3

3/22/2016 How to do the exam? • Start with the heart and IVC • Add components as clinically indicated HIMAP++ HIMAP (pump, tank, pipes) • H eart • H eart • I VC • I VC • M orison’s/FAST • M orison’s/FAST • A orta • A orta • P neumothorax • P neumothorax • Lungs for pulmonary edema • Legs for DVT 4

3/22/2016 Heart • Three questions: - Pericardial effusion/tamponade? - RV failure (massive PE)? - Qualitative assessment of LV function? Parasternal Long Axis View Cardiac Views RV RV LV LV RV RV • Parasternal long and Apical 4-chamber QuickTime™ and a LV LV H.264 decompressor • Small footprint probe (3-5MHz) are needed to see this picture. 5

3/22/2016 Pericardial effusion QuickTime™ and a H.264 decompressor are needed to see this picture. QuickTime™ and a H.264 decompressor are needed to see this picture. QuickTime™ and a VC Coding 6

3/22/2016 QuickTime™ and a QuickTime™ and a VC Coding VC Coding Pericardial vs. Pleural Fluid QuickTime™ and a • Descending thoracic aorta Microsoft Video 1 decompressor are needed to see this picture. 7

3/22/2016 Pericardial effusion Pleural effusion Descending Descending Thoracic Thoracic Aorta Aorta Image source: https://sonospot.wordpress.com Image source: https://sonospot.wordpress.com Pericardial Tamponade • Collapse of the RV during early diastole QuickTime™ and a VC Coding 8

3/22/2016 Pericardial Tamponade QuickTime™ and a VC Coding QuickTime™ and a H.264 decompressor are needed to see this picture. QuickTime™ and a QuickTime™ and a H.264 decompressor VC Coding are needed to see this picture. 9

3/22/2016 Heart • Three questions: - Pericardial effusion/tamponade? QuickTime™ and a H.264 decompressor are needed to see this picture. - RV failure (massive PE)? - Qualitative assessment of LV function? QuickTime™ and a H.264 decompressor are needed to see this picture. 10

3/22/2016 Normal vs. Hypodynamic Left Ventricle Heart Normal Low EF • Three questions: - Pericardial effusion/tamponade? QuickTime™ and a QuickTime™ and a DV/DVCPRO - NTSC decompressor DV/DVCPRO - NTSC decompressor are needed to see this picture. are needed to see this picture. - RV failure (massive PE)? - Qualitative assessment of LV function? Poor EF QuickTime™ and a QuickTime™ and a DV - NTSC decompressor are needed to see this picture. DV/DVCPRO - NTSC decompressor are needed to see this picture. 11

3/22/2016 EPSS • E-point to septal separation (EPSS) • E wave: Early Filling Phase QuickTime™ and a DV/DVCPRO - NTSC decompressor - during diastole, initial wave of blood are needed to see this picture. that enters the left ventricle from the left atrium (70-80%) - A wave: “atrial kick” - normal EPSS is less than 8-10mm Normal Abnormal QuickTime™ and a H.264 decompressor are needed to see this picture. QuickTime™ and a VC Coding 12

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3/22/2016 Fractional Shortening • Another way to estimate EF • Correlates to overall LV contractility • FS of 30-45% = normal LV contractility • [EDD-ESD/EDD] x 100 Image source: https://sonospot.wordpress.com Normal vs. Hypodynamic Left Ventricle Normal Low EF QuickTime™ and a QuickTime™ and a DV/DVCPRO - NTSC decompressor DV/DVCPRO - NTSC decompressor are needed to see this picture. are needed to see this picture. Image source: https://sonospot.wordpress.com 14

3/22/2016 Hyperdynamic LV • LV walls change >90% between systole QuickTime™ and a H.264 decompressor are needed to see this picture. and diastole • LV walls touch at end-systole Heart HIMAP ✓ H eart • Three questions: • I VC ✓ Pericardial effusion/tamponade? • M orison’s/FAST ✓ RV failure (massive PE)? • A orta ✓ Qualitative assessment of LV • P neumothorax function? 15

3/22/2016 IVC HIMAP Indicator toward chin Aim towards thoracic spine • H eart • IVC • M orison’s/FAST • A orta • P neumothorax IVC IVC IVC Image the IVC entering Right Atrium RA QuickTime™ and a H.264 decompressor are needed to see this picture. IVC 16

3/22/2016 IVC IVCi IVCe Goals cephalad caudad cephalad caudad diaphragm liver diaphragm liver QuickTime™ and a QuickTime™ and a TIFF decompressor TIFF decompressor are needed to see this picture. are needed to see this picture. • Assess for IVC fullness • Assess for collapse with inspiration RA border RA border - 2-3cm inferior to right atrial junction • Note collapsibility IVC IVC & CVP Expiration Inspiration QuickTime™ and a H.264 decompressor are needed to see this picture. 2-3 cm QuickTime™ and a H.264 decompressor are needed to see this picture. QuickTime™ and a H.264 decompressor are needed to see this picture. 17

3/22/2016 Pitfalls: IVC vs Aorta Can’t find the IVC? QuickTime™ and a QuickTime™ and a H.264 decompressor H.264 decompressor are needed to see this picture. are needed to see this picture. • Use the internal jugular veins • Note collapsibility during respiratory • Empties into heart ● Flows deep to cycle heart • Flows through liver ● Flows deep to liver • Undulating Pulsation ● Bounding Pulsation HIMAP ✓ H eart ✓ I VC • M orison’s/FAST • A orta • P neumothorax Image source: Seif et al. CCRP 18

3/22/2016 FAST Exam 1. Hepatorenal - Morison’s* 2. Splenorenal* Morison’s Pouch 2 4 1 4 3. Suprapubic 3 *include thoracic views QuickTime™ and a QuickTime™ and a VC Coding VC Coding 19

3/22/2016 Don’t forget the pleural FAST Exam space! 1. Hepatorenal - Morison’s* 2. Splenorenal* 4 2 4 1 3. Suprapubic QuickTime™ and a VC Coding 3 *include thoracic views Splenorenal QuickTime™ and a Spleen VC Coding Recess Costophrenic recess Kidney Hyperechoic Diaphragm 20

3/22/2016 Don’t forget the pleural space! Suprapubic Transverse Longitudinal QuickTime™ and a VC Coding Pelvic View Pelvic View Transverse: Transverse: Female Male Abnormal Uterus Abnormal Abnormal 21

3/22/2016 Pelvic View Pelvic View Longitudinal: Longitudinal: Female Male Abnormal Abnormal HIMAP Aorta ✓ H eart • 2 dimensions ✓ I VC • Image through the bifurcation ✓ M orison’s/FAST • A orta • Look for AAA or dissection • P neumothorax 22

3/22/2016 QuickTime™ and a QuickTime™ and a VC Coding VC Coding 23

3/22/2016 QuickTime™ and a QuickTime™ and a VC Coding VC Coding 24

3/22/2016 HIMAP Pneumothorax ✓ H eart • Linear transducer ✓ I VC • Indicator towards the head ✓ M orison’s/FAST • Anterior intercostal spaces ✓ A orta • Bilateral • P neumothorax QuickTime™ and a QuickTime™ and a VC Coding VC Coding 25

3/22/2016 QuickTime™ and a VC Coding Image source: Seif et al. CCRP HIMAP++ HIMAP (pump, tank, pipes) • H eart ✓ H eart • I VC ✓ I VC • M orison’s/FAST ✓ M orison’s/FAST • A orta ✓ A orta • P neumothorax ✓ P neumothorax • Lungs for pulmonary edema • Legs for DVT 26

3/22/2016 Arise from the pleural line Move with lung slidin Pulmonary Edema Well-defined 3 per rib space B lines = B lines = Reach screen edge interstitial interstitial syndrome syndrome QuickTime™ and a DV/DVCPRO - NTSC decompressor are needed to see this picture. Acute Interstitial Syndrome B lines = increased fluid in the interstitium A Lines B Lines Pulmonary Edema Normal Lung Pneumonia COPD QuickTime™ and a DV - NTSC decompressor QuickTime™ and a Interstitial Fibrosis are needed to see this picture. Microsoft Video 1 decompressor are needed to see this picture. QuickTime™ and a H.264 decompressor Asthma are needed to see this picture. ARDS Lung Contusion 27

3/22/2016 A lines = Dry QuickTime™ and a DV - NTSC decompressor are needed to see this picture. QuickTime™ and a H.264 decompressor are needed to see this picture. HIMAP++ (pump, tank, pipes) • H eart • I VC • M orison’s/FAST QuickTime™ and a QuickTime™ and a H.264 decompressor H.264 decompressor are needed to see this picture. are needed to see this picture. • A orta • P neumothorax A lines = Dry A lines = Dry B lines = Wet B lines = Wet • Lungs for pulmonary edema • Legs for DVT 28

3/22/2016 QuickTime™ and a DV - NTSC decompressor are needed to see this picture. QuickTime™ and a VC Coding 29