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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 -

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Undifferentiated Hypotension

Aparajita Sohoni MD Alameda Health System - Highland Hospital April 7, 2016

Disclosures

  • I have no relevant financial relationships

to discloseI will not discuss any off-label use and/or investigational use in my presentation

  • *Thanks to Arun Nagdev MD for use of slides/videos in

preparation of this talk.

US Protocols for Shock

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RUSH

  • Rapid Ultrasound for Shock and

Hypotension

Outline

  • What?
  • Why?
  • When?
  • How?
  • Cases

What is the RUSH exam?

  • Rapid, systematic evaluation of:
  • heart (pump)
  • effective intravascular status (tank)
  • arterial/venous circulation (pipes)

HIMAP

  • Heart
  • IVC
  • Morison’s/FAST
  • Aorta
  • Pneumothorax
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Why do we do it?

  • Assess etiology of shock
  • Reversible causes of shock
  • Guide resuscitation

Types of Shock

  • Hypovolemic
  • Cardiogenic
  • Obstructive
  • Distributive

When?

  • Unexplained hypotension or shock
  • Part of the primary resuscitation
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How to do the exam?

  • Start with the heart and IVC
  • Add components as clinically indicated

HIMAP

  • Heart
  • IVC
  • Morison’s/FAST
  • Aorta
  • Pneumothorax

HIMAP++

(pump, tank, pipes)

  • Heart
  • IVC
  • Morison’s/FAST
  • Aorta
  • Pneumothorax
  • Lungs for pulmonary edema
  • Legs for DVT
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Heart

  • Three questions:
  • Pericardial effusion/tamponade?
  • RV failure (massive PE)?
  • Qualitative assessment of LV

function?

Cardiac Views

  • Parasternal long and Apical 4-chamber
  • Small footprint probe (3-5MHz)

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LV LV

RV RV

Parasternal Long Axis View

LV LV

RV RV

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Pericardial effusion

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Pericardial vs. Pleural Fluid

  • Descending thoracic aorta
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Pleural effusion Descending Thoracic Aorta

Image source: https://sonospot.wordpress.com Image source: https://sonospot.wordpress.com

Pericardial effusion Descending Thoracic Aorta

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Pericardial Tamponade

  • Collapse of the RV during early diastole
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QuickTime™ and a VC Coding

Pericardial Tamponade

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Heart

  • Three questions:
  • Pericardial effusion/tamponade?
  • RV failure (massive PE)?
  • Qualitative assessment of LV

function?

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Heart

  • Three questions:
  • Pericardial effusion/tamponade?
  • RV failure (massive PE)?
  • Qualitative assessment of LV function?

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Normal Low EF

Normal vs. Hypodynamic Left Ventricle

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Poor EF

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EPSS

  • E-point to septal separation (EPSS)
  • E wave: Early Filling Phase
  • during diastole, initial wave of blood

that enters the left ventricle from the left atrium (70-80%)

  • A wave: “atrial kick”
  • normal EPSS is less than 8-10mm

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Normal

Abnormal

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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 Image source: https://sonospot.wordpress.com

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Normal Low EF

Normal vs. Hypodynamic Left Ventricle

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Hyperdynamic LV

  • LV walls change >90% between systole

and diastole

  • LV walls touch at end-systole

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Heart

  • Three questions:

✓Pericardial effusion/tamponade? ✓RV failure (massive PE)? ✓Qualitative assessment of LV

function?

HIMAP

✓Heart

  • IVC
  • Morison’s/FAST
  • Aorta
  • Pneumothorax
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HIMAP

  • Heart
  • IVC
  • Morison’s/FAST
  • Aorta
  • Pneumothorax

IVC

Indicator toward chin Aim towards thoracic spine RA IVC

IVC

Image the IVC entering Right Atrium

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IVC IVC

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  • Assess for IVC fullness
  • Assess for collapse with inspiration
  • 2-3cm inferior to right atrial junction
  • Note collapsibility

IVC Goals

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cephalad caudad diaphragm RA border cephalad caudad diaphragm RA border

IVCi IVCe

liver liver

Expiration

IVC

Inspiration

2-3 cm

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IVC & CVP

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IVC vs Aorta

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  • Empties into heart
  • Flows deep to

heart

  • Flows through liver
  • Flows deep to

liver

  • Undulating Pulsation
  • Bounding

Pulsation

Pitfalls:

Can’t find the IVC?

  • Use the internal jugular veins
  • Note collapsibility during respiratory

cycle

Image source: Seif et al. CCRP

HIMAP

✓Heart ✓IVC

  • Morison’s/FAST
  • Aorta
  • Pneumothorax
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  • 1. Hepatorenal -

Morison’s*

  • 2. Splenorenal*
  • 3. Suprapubic

3 4 4 1 2

FAST Exam

*include thoracic views Morison’s Pouch

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Don’t forget the pleural space!

  • 1. Hepatorenal -

Morison’s*

  • 2. Splenorenal*
  • 3. Suprapubic

3 4 4 1 2

FAST Exam

*include thoracic views Splenorenal Recess Spleen Kidney Hyperechoic Diaphragm Costophrenic recess

QuickTime™ and a VC Coding

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Don’t forget the pleural space!

Suprapubic

Transverse Longitudinal

Pelvic View Transverse: Male

Abnormal

Pelvic View Transverse: Female Abnormal

Abnormal

Uterus

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Pelvic View Longitudinal: Male

Abnormal

Pelvic View Longitudinal: Female

Abnormal

HIMAP

✓Heart ✓IVC ✓Morison’s/FAST

  • Aorta
  • Pneumothorax

Aorta

  • 2 dimensions
  • Image through the bifurcation
  • Look for AAA or dissection
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QuickTime™ and a VC Coding QuickTime™ and a VC Coding

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QuickTime™ and a VC Coding QuickTime™ and a VC Coding

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HIMAP

✓Heart ✓IVC ✓Morison’s/FAST ✓Aorta

  • Pneumothorax

Pneumothorax

  • Linear transducer
  • Indicator towards the head
  • Anterior intercostal spaces
  • Bilateral

QuickTime™ and a VC Coding QuickTime™ and a VC Coding

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QuickTime™ and a VC Coding

Image source: Seif et al. CCRP

HIMAP

✓Heart ✓IVC ✓Morison’s/FAST ✓Aorta ✓Pneumothorax

HIMAP++

(pump, tank, pipes)

  • Heart
  • IVC
  • Morison’s/FAST
  • Aorta
  • Pneumothorax
  • Lungs for pulmonary edema
  • Legs for DVT
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Pulmonary Edema

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Acute Interstitial Syndrome

Arise from the pleural line Well-defined

B lines = interstitial syndrome B lines = interstitial syndrome

Move with lung slidin 3 per rib space Reach screen edge

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A Lines B Lines

Normal Lung COPD Asthma Pulmonary Edema Pneumonia Interstitial Fibrosis ARDS Lung Contusion

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B lines = increased fluid in the interstitium

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A lines = Dry

B lines = Wet B lines = Wet

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A lines = Dry A lines = Dry

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HIMAP++

(pump, tank, pipes)

  • Heart
  • IVC
  • Morison’s/FAST
  • Aorta
  • Pneumothorax
  • Lungs for pulmonary edema
  • Legs for DVT
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Overwhelmed ?

  • Don’t have to do everything
  • n everyone
  • Start with heart and IVC on

everyone

Outline

  • What?
  • Why?
  • When?
  • How?
  • Cases

Case 1

32 y/o Dev. Delayed male Code 3 by EMS SVT and respiratory distress

Phonating Decreased BS

  • n Left base

Extreme Tachy Irregular rhythm Pulses weak No Edema HR 242 BP 90/palp RR 34 SaO2 90%

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ED Course

  • Pacer pads placed.
  • Adenosine drawn up.
  • Ultrasound machine to the bedside.

Bedside Echo, Apical

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Echo findings:

  • Pericardial effusion:

Huge

  • Cardiac Function:

Hyperdynamic LV RV collapse

  • Central Venous:

High Pressure

= Impending Tamponade

Case 2

83 y/o M CHF, LVEF 20% Febrile, Hypotensive Altered

BP 88/50 HR 110 R 18 O2 96% T 101.3

Phonating, Mumbling Bibasilar Rales Nml chest rise Tachy Reg rhythm Pulses weak 2+ Pitting Edema

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Parasternal Long Axis

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Parasternal Short Axis

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Apical 4 Chamber

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IVC

Echo findings:

  • Pericardial effusion:

No

  • Cardiac Function:

Depressed LV Fxn

  • Central Venous:

Low/Normal Pressure

= Give me fluids

Case 3

46 y/o F with no PMH Palpitations and Dyspnea

BP 80/40 HR 152 R 32 O2 90% T 98.4

Speaking Full Sentences CTA B Kussmaul Respirations Tachy Reg rhythm Pulses Normal No Edema

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Parasternal Long Axis RV - Large & Hypokinetic LV - Small & Hyperkinetic Normal

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Parasternal Short Axis

“D”-Shaped Left Ventricle D

RV - Large & Hypokinetic LV - Small & Hyperkinetic (Septal Wall Flattening) Normal

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RV - Large & Hypokinetic LV - Small & Hyperkinetic RVD:LVD >1 (normal<1)

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Apical 4 Chamber Normal

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IVC IVC= Plethoric (Full, Stiff)

Echo findings:

  • Pericardial effusion: No
  • Cardiac Function:

Hyperdynamic LV RV Dysfunction

  • (RV dilation,

Pulm HTN)

  • Central Venous:

High Pressure =High Suspicion for Submassive Pulmonary Embolism

Conclusions

  • Valuable tool for evaluation of critically

ill hypotensive patients

  • Become comfortable with heart and IVC

views; add on more as you go

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Where can I learn more?

  • Weingart S, et al. The RUSH Exam: Rapid

Ultrasound for Shock and Hypotension (http://emcrit.org/rush-exam/)

  • Seif D, Pereira P, Mailhot T, et al. Bedside

ultrasound in resuscitation and the rapid ultrasound in shock protocol. Crit Care Research & Practice. August 2012.

  • Sonospot.wordpress.com (cases & review)

Questions?