The Arrested Patient
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The Arrested Patient

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Critical Care Ultrasound Training

Critical Care Ultrasound Training

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The Arrested Patient The Arrested Patient Presentation Transcript

  • The arrested patient Ad apted from Lichtenstein's SESAME protocol (with permission)
  • Summary
    • (Ongoing resus) Clinical assessment: formulate the question
    • Rapid arrest screen
    • Form a working diagnosis
    • Continue resuscitation
    • Re-scan / monitor progress / further investigations
  • 1. Formulate the question
  • 1. Formulate the question
    • Why is the patient arrested: is there a reversible cause?
    • b. H ave I successfully intubated? (If ETCO2 not recording)
  • Is there a reversible cause? Tension PTX Tamponade Toxins Thrombosis (MI) Thromboembolism (PE) Hypovolaemia Hypothermia Hypoglycaemia Hyperkalaemia Hydrogen (acidosis)
  • Is there a reversible cause? Tension PTX Tamponade Toxins Thrombosis (MI) Thromboembolism (PE) Hypovolaemia Hypothermia Hypoglycaemia Hyperkalaemia Hydrogen (acidosis)
  • Successful intubation? Bilateral pleural sliding = both lungs ventilated Unilateral sliding = 1 lung ventilation / PTX No sliding = maybe the ETT is in the oesophagus / NB bilateral PTX?
  • 2. The arrest screen
  • Curved probe, abdominal preset Sagittal axis Just like FAST!
  • A 3-step scan
    • 1. Single view heart
    • 2. Anterior lung fields (1 point each side)
    • 2. At your discretion:
      • IVC (hypovolaemia)
      • Abdo (eg AAA / free fluid in trauma)
      • Or finish scanning
  • Don ’ t get in the way of CPR You need to scan during the pulse check You have ten seconds! CPR Pulse check & scan lungs CPR Pulse check & scan heart CPR Pulse check & consider options
  • The arrest scan
  • Step 1 Single view of heart
  • What am I looking for? Is there a heartbeat? Pericardial effusion? RV > LV?
  • Step 1: single view heart
    • Using the curved probe, subcostal view is easiest
    • Probe transverse , marker to patient's right
    • ID heart (probe angled cephalad)
    • Options if you can't obtain an adequate view:
      • Try different window (apical, parasternal)
      • Try different probe (phased array)
      • Get help
  • Subcostal scan heart
  • 1
  • Big RV
    • squashing LV
    • It's a PE
    • Caveats:
    • Is it chronic? Thickened RV wall
    • Is it dilated? Intra arrest
    • Action: consider thrombolysis
    • If in doubt, consider 3-point DVT scan
  • 2
  • Pericardial fluid It ’ s a tamponade Caveat: it might be an incidental finding What if you ’ re wrong? What have you got to lose? Action: pericardiocentesis
  • 3
  • Active heart, small LV = PEA Pseudo-EMD Hypovolaemia Action: replace volume Find & treat cause = go to step 3
  • 4
  • Cardiac standstill Exclude other reversible causes (Hs, Ts) Action: cease CPR
  • Inadequate view Options: Try another window Try cardiac probe Get help
  • Step 1: single view heart Big RV S quashing LV Pericardial fluid Cardiac standstill Inadequate view Small volume heart beating ?
  • Step 1: single view heart Big RV Pericardial fluid Cardiac standstill Inadequate view Pseudo-EMD PE Consider thrombo-lysis Tamponade Drainage Hypovolaemia IV fluid Proceed to step 3 R.I.P. Exclude other reversible causes Cease CPR Keep looking Get help
  • Step 1: single view heart Pseudo-EMD Hypovolaemia IV fluid Proceed to step 2
  • Step 2 Anterior chest
  • Step 2: anterior chest
    • Probe sagittal, midclavicular line
    • Just 1 spot on each side
    • Ideally the most elevated portion of chest
  • TOP TIP: you don ’ t need to be exact
    • If tension PTX, it will fill the hemithorax
    • You ’ ll see it anywhere on the anterior chest
  • Step 2 findings Neither lung is sliding? One lung is not sliding? Both lungs sliding
  • Step 2 findings Neither lung is sliding? One lung is not sliding? Both lungs ventilating PTX or 1 lung ventilation Not ventilating! (NB bilateral PTX?) No PTX Lungs are ventilating
  • Step 2 findings Neither lung is sliding? One lung is not sliding? Both lungs ventilating PTX or 1 lung ventilation Not ventilating! No PTX Check the airway Check the ETT Is there a lung Point (PTO)? Go to step 3
  • Recall: the lung point At the edge of a PTX, you can sometimes see normal lung moving US image: 1 side of image doesn't slide with breathing (= the PTX); the other side shows sliding (= the lung) This spot is the lung point & is 100% specific to PTX
  • What if there's no lung point? Maybe 1 lung ventilation Maybe a massive PTX ( entire lung collapsed)
  • What if there's no lung point? Maybe 1 lung ventilation Maybe a massive PTX ( entire lung collapsed) Be a doctor Go back to clinical picture & urgently drain the PTX or pull back the ETT
  • Step 3
    • Hypovolaemia
    • What ’ s the cause?
    • At your discretion:
      • Review clinical picture
      • Scan the IVC ( confirm hypovolaemia)
      • Scan the abdomen (eg AAA / free fluid in trauma)
  • Recap: the arrest screen
  • A 3-step scan
    • 1. Anterior lung fields
    • 2. Single view heart
    • 3. At your discretion:
      • IVC (hypovolaemia)
      • Abdo (eg AAA / free fluid in trauma)
      • Or finish scanning
  • Step 1: single view heart Big RV Pericardial fluid Cardiac standstill Inadequate view Pseudo-EMD PE Consider thrombo-lysis Tamponade Drainage Hypovolaemia IV fluid Proceed to step 3 R.I.P. Cease CPR Keep looking Get help
  • Step 2: anterior lungs Neither lung is sliding? One lung is not sliding? Both lungs ventilating PTX or 1 lung ventilation Not ventilating! No PTX Check the airway Check the ETT Is there a lung Point (PTO)? Go to step 2
  • Step 3 if hypovolaemia
    • At your discretion:
      • Review clinical picture
      • Scan the IVC (confirm hypovolaemia)
      • Scan the abdomen (eg AAA / free fluid in trauma)
  • Watch the video again
  • Further tests? when resuscitation phase completed
  • Arrest screen: summary
    • Don ’ t get in the way of CPR
    • Ten seconds for each step
    • Make a working diagnosis
    • Re-scan / monitor progress / further investigations