Pierre Kory, MPA, MD Medical Director, Trauma and Life Support - - PowerPoint PPT Presentation

Pierre Kory, MPA, MD Medical Director, Trauma and Life Support Center Chief, Critical Care Service Associate Professor of Medicine University of Wisconsin School of Medicine and Public Health

GO GOALS ALS

 POINT-OF-CARE ULTRASOUND

 BRIEF HISTORY – EVOLUTION - DEFINITION  OVERVIEW OF THE 4 DOMAINS CRITICAL CARE ULTRASOUND

 CRITICAL CARE ECHO – DIFFERENTIATION OF SHOCK STATES

 SEPTIC, HYPOVOLEMIC, CARDIOGENIC, OBSTRUCTIVE - DOES IVC HELP?  CASE BASED OVERVIEW OF SHOCK SYNDROMES  LITERATURE REVIEW SUPPORTING ECHO AS TOOL FOR DIAGNOSIS SHOCK STATES  CARDIAC ARREST STATES – IS TEE THE FUTURE STANDARD OF CARE?

 LUNG ULTRASOUND – DIFFERENTIATION OF ACUTE RESPIRATORY FAILURE  ADDRESS WIDESPREAD INACCURACY IN DIAGNOSIS OF ARF  INTRODUCE 5 ULTRASOUND SIGNS AND DEFINED PATTERNS OF ARF  LITERATURE REVIEW OF IMPACT ON ACCURACY  **RESIDENT CASE SESSION – MORE PRACTICE ASSESSING CASES OF SHOCK

USING ECHO

HIS HISTOR ORY OF BEDSIDE Y OF BEDSIDE DIA DIAGNOS NOSTIC TECHNOL IC TECHNOLOGY



1808 – Laennec’s stethoscope



1888 - Reflex Hammer



1950 –Korean War – Bedside X-ray



1950’s –Ultrasound - Refrigerator size machines

○

Research labs only 

1960’s-70’s – commercial machines



1980’s – Movable, placed on carts



1990’s- DARPA grant – Backpack Ultrasound!



1990’s – Ultrasonography at the Bedside

○

Birth of Point-of-Care Ultrasound

○

Machines smaller, powerful, user friendly, ubiquitous

○

Central venous access - further spread of machines 

2000’s – Portable machines rival quality of larger

Nelson, Heart , 2013 Noble, NEJM 2011

Hist Histor

• ry of car

y of cardiac output iac output monit monitoring in anesthesia ring in anesthesia

Scene from AMC Television Series “The Knick” about a NYC Surgeon in 1905

“Portable” X-Ray - 1952 “Portable” Ultrasound – 2016

THE LA THE LATES TEST AD ADVANCE… “F NCE… “FOREARM” UL OREARM” ULTRASOUND TRASOUND

IMA IMAGING PO ING POWER… IN WER… IN YO YOUR H HANDS

 Miraculous

Properties

 Penetrates through

fluid and solid

• rgans

 Liver, kidney, heart,

spleen ( LUNG)

 Obstructed by bone

and air

**Image taken with lap-top sized machine, 2008,

A “DISR A “DISRUPTIVE” INNO PTIVE” INNOVATION TION



“That which transforms a market by introducing simplicity, convenience, accessibility, and affordability where complication and high cost were the status quo”



INITIALLY, Traditional imagers controlled market

○

expensive, immobile machines, interpreted remotely by experts



SUBSEQUENTLY, Technology led to Hand held/Portables – cheap, high quality images, easy to use, wider spectrum of doctors using the machines

○ devices shown to be of equal efficacy for “decision making”

Nelson, Heart , 2013

POINT POINT-OF-CARE UL OF-CARE ULTRASOUND (POCUS) TRASOUND (POCUS) – SOME DEFINITIONS OME DEFINITIONS

 “ultrasound exam performed by the care PROVIDER in real

time”

 Not saved as a still image to be interpreted later by remote specialist

 “not a complete study, rather an extension of the clinical

examination to rule in or rule out key diagnoses in specific clinical settings”

 “geared to addressing highly time-dependent and focused

questions and, in general, most focused scans become more

• bviously positive as the patient becomes increasingly unwell”

Grifoni Chest 2013 Atkinson J Emerg Med 2011

Stable vs. Unstable Patients

 The benefits of point-of-care ultrasound:  Unstable patients- directs immediate care and potentially

saves lives

 Stable patients - expedites care, reduces ancillary testing,

and educates providers.

Dif Differences betw erences between P een Point-of-Care Ultrasound int-of-Care Ultrasound

• ver T

er Traditional Imaging Pract aditional Imaging Practice ce

• Avoid Clinical Disassociation of Traditional Interpreters
• knowledge of loading conditions, pre-test probability of disease(s) in

question

• Avoid Time Disassociation of Traditional Interpretation
• no delays in performance/interpretation by a remote specialist
• avoid lengthy, “comprehensive” exams – focus components to those most

relevant

• Integrate Exam Findings From Multiple Organ Systems simultaneously-

answer broader questions:

• Why is this patient in shock?
• Why is this patient in respiratory failure?
• Why does this patient not have urine output?
• Why is the patient’s abdomen distended?
• What are causing the bibasilar opacities?

4) Avoid potentially lethal radiation 5) Avoid potentially ”lethal” costs

POCUS POCUS EVOLUTION TION

 1970’s – USA - Ultrasound first used at bedside of trauma patients  1980’s France – Birthplace of Critical Care Ultrasonography

○ ICU Echo in 1980’s, Lung and GCCUS – 1990’s

 TEE now performed as a routine assessment of shock patients

 1990’s- “FAST” exam coined in Emergency Medicine in U.S

○ Part of EM competency requirements since 1994 ○ Precedent for development of ever expanding POCUS applications ○ POCUS now part of nearly every specialties practice

 2000’s - Medical schools now integrating into curriculum

○ Rare for Medicine Residency programs (some recent studies..) ○ Pulmonary/Critical Care Programs – becoming routine

EVOLUTION OF POINT OF CARE ULTRASONOGRAPHY (CCUS)

Soni, Arntfield, Kory, POCUS, 2014

GUIDELINES/RECOMMEND GUIDELINES/RECOMMENDATIONS F IONS FOR R USE OF UL USE OF ULTRASOUND TRASOUND

 AMA

AMA – “ultrasound within scop ultrasound within scope of pr e of pract actice of ( ce of (all) appr ll) appropr

• priat

ately t ely trained-ph ained-physicians” ysicians”

 AHCQR –

AHCQR – one of 12 ne of 12 best practices f best practices for patient saf r patient safety ty (CV (CVC access) access)

 AC

ACGME -

• required c

component o

• f t

training in in several r ral residency and f sidency and fello llowships wships

 PCCM

PCCM Residency R sidency Revie view Committ Committee recommends: ee recommends:

○ “

“ training in training in ultraso ultrasound guided CV nd guided CVC and tho C and thoracent acentesis..” sis..”

○ “demonstrat

“demonstrate kno knowledge of ult ledge of ultrasound im asound imaging t aging techniq chniques us es used in ed in evaluation aluation

• f p

patients w with p pulmonary d disease o

• r c

critical i illness”



AIUM 2004 - AIUM 2004 - “the the concept of an concept of an ‘ultrasound st ‘ultrasound stetho hoscope’ scope’ is rapidly mo is rapidly moving fr ving from the

• m the

the theore retical t l to reality reality.”

 Abraham V

raham Verghe rghese se - “great vie great views of hear

• f heart, adds v

adds volume lumes t s to inf info fr from st

• m stethoscope”
• pe”

 Advocat

cates POCUS t POCUS to im impr prove patient int e patient interaction/PHY raction/PHYSICA ICAL EXAM EXAM

 20

2017 SUR SURVIVING SEPSIS IVING SEPSIS CAMP CAMPAIGN GUIDEL AIGN GUIDELINES INES:

CCUS Rationale/Evidence…? CCUS Rationale/Evidence…?

 Improves safety & Success of venous, pleural, peritoneal,

pericardial cannulation and drainages

 Uncountable cases of unsuspected life-threatening conditions

(AMI, VTE/PE, pleuro-pericardial, valves, aorta, PTX, cardiomyopathy)

 Large improvements in accuracy of diagnosis of shock and

acute respiratory failure

 “suggestion” of improved outcomes

 Sequential exams guide resuscitation, titration of inotropes  Under-reported outcomes/benefits, captured in several studies

but not as primary outcomes – difficult to design studies on diagnostic tools

UNDER UNDER-RECOGNIZED IMP RECOGNIZED IMPACT CT OF CRITICAL CARE OF CRITICAL CARE UL ULTRASOUND: REDUCTION IN IMA TRASOUND: REDUCTION IN IMAGING TES ING TESTS

 Peris A et al, Anaesth Analg, 2010

 Introduced LUS to a group of intensivists. Measured CXR and CT scans

use 3 months before and after LUS training

○ CT’s: 274 to 135 ( 50% decrease) ○ CXR’s: 803 to 589 (40% decrease) ○ *trend to a lower LOS, lower days on ventilator”

 Oks M et al, Chest, 2014

 Compared radiology tests between North Shore ICU (no diagnostic U/S)

and Long Island Jewish (heavy U/S use)

○ 3.75 CXR/pt vs. 0.82 CXR/pt ( p<.05)

○ .1 CT/pt vs.04 CT/pt (p<.05)

○ .17 CT abdo/pt vs. .05 CT Abdo/pt (p<.05)

CRITICAL CARE UL CRITICAL CARE ULTRASONOGRAPHY APPLICA TRASONOGRAPHY APPLICATIONS IONS “WHOLE-BOD HOLE-BODY UL Y ULTRASOUND” TRASOUND”

 CARDIAC  Differentiation of Shock States  Assessment of Fluid Responsiveness?  LUNG and PLEURA  Diagnosis of Causes of Acute Respiratory Failure  Characterization/drainage of pleural pathology  ABDOMINAL  Free Fluid, Obstructive Uropathy, Ischemic Colitis  VASCULAR  Catheter Insertion Guidance  Diagnosis of Deep Venous Thrombosis

BASIC CCE – RECOGNIZING SHOCK SYNDROMES

NEJM REVIEW 2012 – CATEGORIZING SHOCK STATES

Taken From NEJM Review Paper on Management of Shock, 2012

ASE PRESIDENT EDIT ASE PRESIDENT EDITORIAL ON ORIAL ON POCUS 20 POCUS 2016

email FR email FROM F OM FORMER RESIDENTS/FELL RMER RESIDENTS/FELLOWS

 7/27/15 - I just wanted to email you and say a huge thank you for being a

great teacher to me during residency. Also, you were the first to introduce me to critical care ultrasound. I always knew it was an important tool but didn't realize it could be life saving until last week. I was called to evaluate a young 34 year old guy admitted only for cellulitis when he suddenly syncopized became tachycardic hypotensive and diaphoretic.

 Everyone thought he had sepsis and started fluids but I used the ultrasound

and was able to detect acute R heart strain and suspected a massive PE

• instead. He ended up arresting 3 times, was given full dose TPA, went to the

OR and had massive clots pulled out his right and left PAs. He's now extubated with a full mental status and no Neuro deficits. “This is the first

time I can honestly say I saved someone's life and it was all because I knew to use ultrasound.” I thought you'd appreciate the story and also

wanted to tell you again how grateful I am to have had you as a teacher. Wisconsin is lucky!

COMPREHENSIVE VS. FOCUSED ECHO

 Comprehensive Echo:

 More than 70 quantitative assessments provided  Exactly zero of the quantitative measures are critical to answering the

VAST majority of ACUTE clinical questions (in a MICU at least)

○ LA diameter, LV thickness, pressures, velocities, orifice sizes, strain rates,

regurgitation severities…

○ It is a test invented in the quiet of an echo lab, tailored for diagnosis of chronic

and often subtle, vague, undifferentiated complaints or for the follow-up and MONITORING of patients with established and chronic cardiac disease

○ Every Comprehensive Echo has a summary list of statements that are identical

to a FOCUSED echo report – this list is almost solely based on qualitative assessments that can be made in minutes

MANY GOAL DIRECTED EXAM PROTOCOLS exist … all answer the same clinical clinical questions estions..

Seif D, Critical Care Research and Practice, 2012

A Divide between ED and Critical Care Patient Populations?

ASE, ACCP, and ACEP FOCUSED ECHO EXAM 5 Views 5 Assessments

 Global LV size and function  Global RV size and function  Presence of Pericardial Effusion  Intravascular Volume (IVC/LV/RV)  Gross Valvular Structure/Fxn

 *Pattern of findings allow

for diagnosis of shock states

LV Function: Assessment of

Endocardial excursion Myocardial thickening Mitral valve movement

• 1. Endocardial

Excursion

• 2. Myocardial

Thickening

• 3. Mitral Valve

Excursion

Images taken from Kory et al Point of Care Ultrasound 2014

Normal Size/Contractility of both LV and RV

SHOCK SYNDROME CASE 1

 67 y.o male s/p admission for CVA complicated by PNA

and respiratory failure, extubated, transferred to acute rehab floor

 RRT called for dyspnea and hypotension

PARA-STERNAL LONG AXIS

RVOT LV

PARA-STERNAL SHORT AXIS

RV LV

NORMAL ECHO CASE ECHO

INFERIOR VENA CAVA

WHICH CATEGORY/PATTERN OF SHOCK IS PRESENT?

Vasodilatory Normal/Small Size LV/RV, Hyperdynamic vs Normal LVF

Normal/Small IVC

CAT SCAN

THROMBECTOMY

SHOCK S SHOCK SYNDR NDROME CASE 2 ME CASE 2

 75 NHR a/w respiratory failure and shock  Sepsis protocol started in ED based on urine pyuria  Goal-Directed Echo Performed

PARA-STERNAL LONG AXIS

LV RVOT LA

NORMAL ECHO - PSLA

PARA RA-S

• STERNAL SHOR

TERNAL SHORT AXIS T AXIS

PACER WIRE LV RV

NORMAL ECHO - PSSA

APICAL 4 CHAMBER

RV LV RA LA

IVC VIEW

Patient hypoxemic, intubated, now oliguric

WHICH CATEGORY/PATTERN OF SHOCK IS PRESENT?

Vasodilatory Normal/Small Size LV/RV, Hyperdynamic vs Normal LVF

Normal/Small IVC

SHOCK SYNDROME CASE 2

 MULTIFACTORIAL SHOCK?  Distributive by history  Cardiogenic component - tolerated little fluids, poor reserve

○ Prompts more focus for occult/coexisting ischemia

 Inotropic therapy indicated

○ UOP, lactate improved with antibiotics, inotropes, pressors

SHOCK SYNDROME CASE 3

72 year old woman presenting with fever, malaise Initial Vitals T=102 Hr ‐ 122, BP ‐ 80/40, RR ‐ 26 Sepsis protocol initiated, cultures drawn, antibiotics given,lactate = 5.2 3 Liters Crystalloid given, remained hypotensive to 86/42 ‐ norepinephrine initiated, sent to ICU

RVOT LV

IVC VIEW

SHOCK SYNDROME CASE #3

• GDE FINDINGS:
• Normal LV size and function
• Normal RV size and function
• Absence pericardial effusion
• Filled, Invariable IVC

SYNDROME: "Normal Echo” SHOCK = DISTRIBUTIVE, RESUSCITATED TREATMENT: ANTIBIOTICS/VASOPRESSORS

SHOCK SYNDROME CASE 4

 74 y.o woman, sister of Board of Trustee Member, in

hospital for severe Cdiff colitis, recovering. New DVT on anti‐coagulation.

 Routine vital signs taken after dinner one Friday evening

‐ 80/40, HR ‐ 140, RR‐ 28, Afebrile, 97%

 No complaints. Feels weak. LE edema on exam. Pallor.

Rectal Exam ‐ brown stool.

PARA-STERNAL LONG AXIS

PARASTERNAL SHORT AXIS

APICAL 4 CHAMBER

IVC VIEW

SHOCK SYNDROME CASE 4

 GDE Findings

 LV – Hyperdynamic, collapsed chamber mid‐systole “kissing papillary” s  RV – Small chamber, completely collapsible  Absence of Pericardial Effusion  "Virtual" IVC

 SYNDROME: HYPOVOLEMIC ( HEMORRHAGIC) SHOCK  Source notable on para-sternal view!!?  Treatment – hyper-aggressive fluid resuscitation, more IV lines,

pressure bags, blood bank run

 Despite aggressive approach, patient lost mental status, intubated, anuric – recovered

without MOF over several days

EVIDENCE FOR GDE IN SHOCK PATIENTS

 Initial studies – Largely in French/Mt. Sinai ICU’s  Intensivist performed TEE, compared findings with PAC

○ Marked changes in diagnosis and therapy after TEE

 Later studies - ED and ICU Studies of GDE with TTE  Patients with Undifferentiated, Non-Traumatic Hypotension  High Mortality – 18-26% in ED studies  Poor ED Physician Clinical Accuracy

○ One study – ED physician correct initial diagnosis in only 26%

POCUS/GDE IN UNDIFFERENTIATED SHOCK IN THE MERGENCY DEPARTMENT

 Jones, Crit Care Med, 2004  184 non-trauma ED patients  Intervention group received immediate GDE/FAST exam  Control Group received delayed GDE/FAST  Exam required 6 minutes  Most likely diagnosis proved correct in 80% of ultrasound group  Most likely diagnosis proved correct in only 50% control group

TIME FOR PART II????

 ULTRASOUND IN THE DIAGNOSIS AND

MANAGEMENT OF RESPIRATORY FAILURE

 **I have many more cases of shock representing the

spectrum of discrete patterns encountered in critical care, I will do these with the residents after Grand Rounds

IMPACT OF GDE-TEE IN SEPTIC SHOCK

 Vieillard-Baron, 2012  Did GDE-TEE in 46 patients  Used validated Echo criteria for determination of fluid

responsiveness, requirement for inotropes, vasopressors

 Compared Echo Protocol with Surviving Sepsis Protocol

○ 70% of patients – fluid plan in agreement ○ 30% of patients – TEE mandated holding of fluids (despite CVP<12)

 14 patients required inotropes by TEE

○ Only 4 would have gotten inotropes by SSCG

IMPACT OF GDE/LUS IN ED/ICU

 Manno, Anesthesiology 2012 – 58% confirmed dx, 26% changed  Pirozzi, Crit Care Ultrasound, 2014 – 50% wrong dx vs. 5%  Silva, Chest, 2013 – 63% accurate initial dx vs 83%  Bellone, 2013 – 57% accurate initial dx vs. 90.7%  5% vs 2.7% mortality… (P<.01)  All studies involved experienced POCUS clinicians  All studies had high impact on initial diagnostic accuracy

○ “Heart-Lung ultrasound exam is mandated in all patients presenting with

cardiopulmonary failure” – Kory, 2013

2015 AHA GUIDELINES FOR ACLS

 Physiologic Monitoring During CPR:  … we suggest that if cardiac ultrasound can be performed

without interfering with the standard advanced cardiovascular life support protocol, it may be considered as an additional diagnostic tool to identify potentially reversible causes of cardiac arrest

 How does one do cardiac ultrasound without interfering

with ACLS protocols in arrest patients..??

• 54 TEE’s done by 12 ED physicians ( 4 hour simulation course)
• 43% done in cardiac arrest patients
• 78% influenced diagnosis
• 67% impacted therapeutics

TEE DURING CPR IN THE ED BY EP’s

TEE during CPR – Arntfield et al, 2016

 Therapeutic impact in 67% of cases  Change to quality/timing/location of CPR (43%).

○ Misplaced vector of force (in both manually and

automated delivery of CPR), identification of chest compressor fatigue, shortened pulse-check duration, and identification of return cardiac activity during CPR were all described.  TEE findings were additionally noted to influence

prognosis and cessation of resuscitation (30%), and guide hemodynamic support either through volume (18%) or vasoactive drugs (8%) (Figure 3).

WHAT IS WRONG WITH THE CPR BEING DELIVERED HERE?

TEE CPR WITH LVOTO

IS THERE ANY BLOOD GETTING TO THE BRAIN?

First Textbook covering all aspects of POCUS – print and electronic/IPAD version….

There are Endless Uses for Ultrasound in Both Critical Care and Pulmonary Practice

 Differentiating Cardiogenic vs. Non-Cardiogenic Pulmonary Edema  Ruling out out Pulmonary Embolism as cause of shock/hypoxemia/dyspnea  Evaluation of full stomach pre-intubation  Evaluation for ischemic bowel – absence/presence of peristalsis  Rule out of obstructive uropathy  Evaluation for free fluid in abdomen  Transthoracic needle biopsies of ANY pleural or peripheral lung based mass  Chest tube placement into lung abscess  ECMO catheter placememt  Hemidiaphragm assessments  Extubation planning and quantification of lung water  Screening for elevated intracranial pressure  And the list grows..