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Ultrasound in undifferentiated shock

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Ultrasound in undifferentiated shock

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Ultrasound in undifferentiated shock

  1. 1. Ultrasound in Undifferentiated Shock Dr James Wheeler BSC (Hons) MBBS FACEM DDU (General) Emergency Physician SCGH
  2. 2. What we will cover • What is point of care ultrasound – SCGH ED US Service • Shock – Definitions / Causes / Treatments • How US may be used to investigate a patient with undifferentiated shock – Some ultrasound protocols – Limitations of US examination – Some examples of sonographic findings in particular causes of shock • What we won’t cover: – How to perform an ultrasound – Detailed interpretation of ultrasound
  3. 3. Point of Care / Bedside Ultrasound • Use of US at the patients bedside to answer specific clinical questions and assist in clinical diagnosis and management – Also help guide certain procedural treatments (IV access, pericardiocentesis etc…) • Advantages: – Bedside (no transfer out of dept.) – Can be accessed immediately – Nil radiation – Functional imaging (CO, PAP...) – Assessment can be adapted to fit clinical assessment & sonographic findings • Limitations: – Training / experience and operator dependent – Sometimes difficult to obtain certain views (sonographic windows) in critically unwell / unprepared patients
  4. 4. SCGH ED US Service • Established 2005 • Internationally regarded (thanks to Ass Prof James Rippey) • 6 DDU FACEM’s (General and Emergency), 1 Fellow, 1 Registrar – DDU = 2 years supervised US training, primary and secondary exams – One consultant rostered for EDUS 0800-1800 weekdays (afterhours as per our rostering) • Skills of US examination are now becoming an essential part of critical care training – Other members of the ED, and other critical care, staff have varying levels of training and experience in critical care and procedural ultrasound
  5. 5. SCGH ED Service: What do we do? Diagnostic Procedural Critical Care • Abdominal • Reproductive systems • Vascular (some) • Musculo-skeletal (some) • Cardiac • Lung • Ocular • Masses • Vascular access (PVC, CVC, arterial) • Effusion drainage (joint, pleural, pericardial, ascitic) • Abscess drainage • Nerve blocks • Foreign body removal • Cardiac arrest • Major trauma (EFAST) • Chest pain • Collapse • Shortness of breath • Sepsis (?source ?fluids or inotropes) • Pregnancy related abdominal pain • Undifferentiated shock …and Education / Teaching!
  6. 6. Shock • Hypotension Defn: – SBP < 90mmHg – Shock Index (HR/SBP) probably better indicator of potential shock (N 0.5-0.8, SI > 1 ?Shock) • Shock Defn: – Life–threatening condition of circulatory failure resulting in inadequate tissue perfusion, cellular hypoxia and END ORGAN DYSFUNCTION (confusion, renal failure, hepatic failure….) • Undifferentiated Shock: – Shock is recognised, but the cause is unclear
  7. 7. Undifferentiated shock • Relatively common in ED • Important predictor of mortality • Different subtypes of shock require different management (that may be life- saving if done in a timely fashion)
  8. 8. Shock – Causes Cause Example Hypovolaemia Haemorrhage (trauma, AAA, ectopic) GI Loss (gastroenteritis) Renal Loss (DKA) Reduced intake Cardiogenic AMI Cardiomyopathy Valvular failure Ventricular aneurysm / rupture Obstructive Tension PTX Tamponade Massive PE HCM Atrial myxoma Distributive Sepsis Anaphylaxis Neurogenic Toxicological
  9. 9. Evidence – US in Shock • Overall very good agreement (90 – 100%) between the US diagnosis (~20mins post arrival) and final diagnosis (k = 0.71 – 0.9) 1, 2, 3 • Changes in Mx: – Decreases physician diagnostic uncertainty – Increased patients with transferred from ED with a definitive diagnosis – 24.6% of patients had a significant change in the use of IV fluids, vasoactive agents, or blood products. 2 – Major diagnostic imaging (30.5%), consultation (13.6%), and emergency department disposition (11.9%) 2
  10. 10. Patients evaluated with POCUS had less time on vasopressors and showed trends toward fewer days in the ICU and decreased morbidity • Unpublished • April 2016 • 45 patients (22 had US, 23 did not) in ICU (Portland USA) • Assessed fluid responsiveness (resp change in IVC diameter, LVOT VTI after SLR) • Results: – 38% reduction in time on vasopressor (p = 0.038) – Trends to reduction in hours on ventilators and days in ICU (see next slide) – Calculated savings of ~$20,000 / patient Impact of POCUS on therapy POCUS group Control group p-value Total hours on vasopressors 36.43 58.57 0.038 Hours to 50% wean off vasopressors 22.24 40.66 0.0952 Total hours on ventilator 68.3 133.67 0.283 Days in ICU 4.41 6.67 0.2
  11. 11. US in Undifferentiated Shock • Many different target-directed US exams developed to determine cause/s of shock • At SCGH ED often tailored / focused US examination to answer clinical questions relevant to the clinical assessment of the patient • Note: US also useful in guiding treatment procedures and monitoring response to treatment in this patient group
  12. 12. US Protocols for Shock Assessment: The image part with relationship ID rId2 was not found in the file.
  13. 13. Rapid Ultrasound in Shock (RUSH)
  14. 14. Rapid Ultrasound in Shock (RUSH) The image part with relationship ID rId2 was not found in the file.
  15. 15. Best Views
  16. 16. Rapid Ultrasound in Shock (RUSH) The image part with relationship ID rId2 was not found in the file.
  17. 17. Rapid Ultrasound in Shock (RUSH) The image part with relationship ID rId2 was not found in the file.
  18. 18. Hypovalaemia Shock • Haemorrhage – Ruptured AAA / Ectopic Pregnancy / Solid organ injury / Thoracic injury • GI Loss – Gastroenteritis • Renal loss – DKA • Reduced Intake
  19. 19. Hypovolaemia - IVC Collapse / Variability
  20. 20. Hypovolaemia - IVC Collapse / Variability
  21. 21. Hypovalemia - IP Free Fluid / Haemorrhage
  22. 22. Hypovalemia - IP Free Fluid / Haemorrhage
  23. 23. Hypovolaemia – Ruptured Ectopic Pregnancy
  24. 24. Hypovolaemia – AAA (?signs of rupture)
  25. 25. Hypovolaemia – AAA (?signs of rupture)
  26. 26. Aortic Dissection
  27. 27. Aortic Dissection
  28. 28. Cardiogenic Shock • AMI • Acute valvular dysfunction • Ventricular aneurysm • Cardiac rupture • Cardiomyopathy (acute or chronic)
  29. 29. Cardiogenic – LV Contractility
  30. 30. Cardiogenic – LV Contractility
  31. 31. Cardiogenic - AMI – RWM AbN
  32. 32. Cardiogenic - AMI – RWM AbN
  33. 33. Cardiogenic – Pulmonary Oedema
  34. 34. Cardiogenic - APO & Pleural Effusions
  35. 35. Cardiogenic - APO & Pleural Effusions
  36. 36. Obstructive Shock • Massive or Sub-Massive PE • Cardiac Tamponade • Tension PTX
  37. 37. Obstructive – PE
  38. 38. Obstructive – PE - RV Dilatation
  39. 39. Obstructive – PE - RV Dilatation
  40. 40. Obstructive – PE - RV Dilatation / Contractility
  41. 41. Obstructive – PE - RV Dilatation / Contractility
  42. 42. Obstructive – PE / Tamponade: IVC Fixed Distension
  43. 43. DVT
  44. 44. Obstructive – Pericardial Tamponade (Subcostal)
  45. 45. Obstructive – Pericardial Tamponade (PLX)
  46. 46. Obstructive – Pericardial Effusion (PLX)
  47. 47. Obstructive – ??Pericardial Effusion
  48. 48. Obstructive - ?Tension Pneumothorax
  49. 49. Lung Contact Point
  50. 50. Thoracic Aortic Aneurysm with Tamponade
  51. 51. Distributive Shock • Sepsis (?source) • Anaphylaxis • High Spinal Injury • Toxicological Vasoplegia
  52. 52. Distributive – Intraperitoneal Gas & Fluid
  53. 53. Distributive – ?Sepsis Source
  54. 54. References: 1. Ghane et al. Accuracy of Rapid Ultrasound in Shock (RUSH) Exam for Diagnosis of Shock in Critically Ill Patients. J Emerg Trauma Shock. 2015 Jan-Mar;8(1):5-10. 2. Shokoohi et al. Bedside Ultrasound Reduces Diagnostic Uncertainty and Guides Resuscitation in Patients With Undifferentiated Hypotension. Crit Care Med. 2015 Dec;43(12):2562-9 3. Volpicelli et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med (2013) 39:1290–1298

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