Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Introduction to critical care US SAH & RNSH 2011 Critical Care Ultrasound Course
Goals of today's course <ul><li>Understand critical care ultrasound </li></ul><ul><li>Understand its limitations (& your o...
A real case (My road to Damascus) <ul><li>shocked  30 yr old male </li></ul><ul><li>breathless & severe chest pain </li></...
Initial investigations <ul><li>CXR clear </li></ul><ul><li>ECG non specific </li></ul><ul><li>ABG markedly abnormal gas ex...
Atypical pneumonia? Or a PE?
OK, let ’ s get a scan. <ul><li>Too unstable for CT / VQ scan </li></ul><ul><li>Cardiology:  ‘ too busy ’ </li></ul><ul><l...
#*%* !!!
Get out the ED US machine! <ul><li>Lungs </li></ul><ul><li>IVC </li></ul><ul><li>Heart </li></ul><ul><li>Leg veins </li></ul>
Lungs clear
Non-collapsing IVC
RV > LV
DVT
Results <ul><li>Lungs clear </li></ul><ul><li>Distended IVC </li></ul><ul><li>High pressure dilated RV > LV </li></ul><ul>...
Massive PE <ul><li>Working diagnosis: massive PE (not atypical pneumonia) </li></ul><ul><li>Treatment: ED thrombolysis </l...
Essential features of any bedside test in critical care <ul><li>Improves accuracy of diagnosis in the critically ill (preh...
BSL ECG O2 Sats
Bedside Critical Care US (CCUS)
Why? <ul><li>A simple 3-minute ultrasound can assist in diagnosis and resuscitation </li></ul><ul><li>It may not give you ...
What is critical care US? <ul><li>A rapid,  patient -focused  bedside US scan </li></ul><ul><li>Initial rapid scan: lungs ...
Why isn't focused TTE enough? <ul><li>Focused TTE </li></ul><ul><li>1. Just looks at heart </li></ul><ul><li>2. Cardiac pr...
Does the screen really take 3 minutes?
Why isn't focused TTE enough? <ul><li>Cardiac sonographer: 'the DDx between pericardial & left pleural fluid can be subtle...
Duh! Just look at the left thorax
This is why focused TTE isn ’ t enough <ul><li>Cardiologists look after the heart  ->  echocardiography just looks at the ...
Whole-body  ultrasound
Current standard of critical care ultrasound <ul><li>LUNG </li></ul><ul><li>IVC </li></ul><ul><li>HEART </li></ul><ul><li>...
An important note <ul><li>Cardiologist: 'Why do you want an urgent echo? Echo can't rule out a PE' </li></ul><ul><li>ED ph...
Top tip: bloody sick = bloody obvious We're not looking for small pneumothorax or mild CCF ('rule-in', not 'rule-out') If ...
<ul><li>A formal echocardiogram </li></ul><ul><li>It doesn't use M-mode or Doppler </li></ul><ul><li>It doesn't look for s...
Limitations of critical care US <ul><li>Algorithm: only validated in critically unwell patients </li></ul><ul><li>Patient:...
So: the golden rules 1.  'Resus-only':  Patient must be critically unwell: shocked / breathless / peri-arrest.  That's bec...
Golden rules 5. 90% = 100%:  Every test has its limitations. In a periarrest patient, no study will be 100% accurate. If t...
Golden rules 6. When in doubt, be a doctor.  You were a clinician before you were a sonographer. If the clinical picture &...
The golden rules 1. 'Resus-only' 2. Clinical context is paramount. 3. Only ask questions that you can answer. 4. Repeat sc...
7. A fool with a stethoscope will be a fool with an ultrasound
Critical care US <ul><li>It’s not the Holy Grail </li></ul><ul><li>Just another tool </li></ul><ul><li>Rapid </li></ul><ul...
Thanks to Daniel Lichtenstein Paul Atkinson Conn Russell Rob Reardon Vicki Noble Russell McLaughlin (for rule #7)
References <ul><li>Blaivas M, Lyon M, Duggal S. A Prospective Comparison of Supine Chest Radiography and Bedside Ultrasoun...
PS Even if I hand't performed an US, I probably still would ’ ve thrombolysed him.
Upcoming SlideShare
Loading in …5
×

Introduction to Critical Care Ultrasound

18,377 views

Published on

Critical Care Ultrasound Training

Published in: Health & Medicine

Introduction to Critical Care Ultrasound

  1. 1. Introduction to critical care US SAH & RNSH 2011 Critical Care Ultrasound Course
  2. 2. Goals of today's course <ul><li>Understand critical care ultrasound </li></ul><ul><li>Understand its limitations (& your own) </li></ul><ul><li>Learn the basics of lung, IVC and cardiac sonography </li></ul><ul><li>Learn the arrest / shock / breathless algorithms </li></ul><ul><li>Perform a 3-minute screen </li></ul>
  3. 3. A real case (My road to Damascus) <ul><li>shocked 30 yr old male </li></ul><ul><li>breathless & severe chest pain </li></ul><ul><li>mildly febrile , heart racing </li></ul><ul><li>unresponsive to O2 / fluid / antibiotics </li></ul><ul><li>Recovering from a common cold </li></ul><ul><li>no RFs for the usuals </li></ul><ul><li>getting worse in front of us </li></ul>
  4. 4. Initial investigations <ul><li>CXR clear </li></ul><ul><li>ECG non specific </li></ul><ul><li>ABG markedly abnormal gas exchange </li></ul>
  5. 5. Atypical pneumonia? Or a PE?
  6. 6. OK, let ’ s get a scan. <ul><li>Too unstable for CT / VQ scan </li></ul><ul><li>Cardiology: ‘ too busy ’ </li></ul><ul><li>Radiology: ‘ we don ’ t do echo ’ </li></ul>
  7. 7. #*%* !!!
  8. 8. Get out the ED US machine! <ul><li>Lungs </li></ul><ul><li>IVC </li></ul><ul><li>Heart </li></ul><ul><li>Leg veins </li></ul>
  9. 9. Lungs clear
  10. 10. Non-collapsing IVC
  11. 11. RV > LV
  12. 12. DVT
  13. 13. Results <ul><li>Lungs clear </li></ul><ul><li>Distended IVC </li></ul><ul><li>High pressure dilated RV > LV </li></ul><ul><li>DVT </li></ul><ul><li>Diagnosis? </li></ul>
  14. 14. Massive PE <ul><li>Working diagnosis: massive PE (not atypical pneumonia) </li></ul><ul><li>Treatment: ED thrombolysis </li></ul><ul><li>Rapid improvement </li></ul>
  15. 15. Essential features of any bedside test in critical care <ul><li>Improves accuracy of diagnosis in the critically ill (prehospital, ED, ICU) </li></ul><ul><li>Guides treatment / resuscitation / procedures </li></ul><ul><li>Rapid </li></ul><ul><li>Simple </li></ul><ul><li>Repeatable </li></ul>
  16. 16. BSL ECG O2 Sats
  17. 17. Bedside Critical Care US (CCUS)
  18. 18. Why? <ul><li>A simple 3-minute ultrasound can assist in diagnosis and resuscitation </li></ul><ul><li>It may not give you the final diagnosis </li></ul><ul><li>But it buys you the time to perform a more detailed assessment once stabilised </li></ul><ul><ul><li>EG a focused TTE </li></ul></ul><ul><ul><li>EG a CT scan </li></ul></ul>
  19. 19. What is critical care US? <ul><li>A rapid, patient -focused bedside US scan </li></ul><ul><li>Initial rapid scan: lungs / IVC / heart (curved probe) / other areas as appropriate </li></ul><ul><li>Then, after initial resuscitation, a more rigorous look at specific areas as indicated: </li></ul><ul><li>Heart / Lungs / Abdomen / Leg veins </li></ul>
  20. 20. Why isn't focused TTE enough? <ul><li>Focused TTE </li></ul><ul><li>1. Just looks at heart </li></ul><ul><li>2. Cardiac probe / preset </li></ul><ul><li>3. Difficult windows </li></ul><ul><li>4. Slow learning curve </li></ul><ul><li>5. Takes several minutes </li></ul><ul><li>6. No cardiac windows = no information </li></ul><ul><li>7. Adapted from formal TTE </li></ul><ul><li>Rapid CCUS screen </li></ul><ul><li>1. Heart / lung / IVC / veins </li></ul><ul><li>2. Curved probe / abdo preset </li></ul><ul><li>3. Simple windows </li></ul><ul><li>4. Rapid learning curve </li></ul><ul><li>5. Takes 3 minutes </li></ul><ul><li>6. Works even if you can't see the heart / IVC </li></ul><ul><li>7. Purpose-built & validated for critical care </li></ul>
  21. 21. Does the screen really take 3 minutes?
  22. 22. Why isn't focused TTE enough? <ul><li>Cardiac sonographer: 'the DDx between pericardial & left pleural fluid can be subtle' </li></ul>
  23. 23. Duh! Just look at the left thorax
  24. 24. This is why focused TTE isn ’ t enough <ul><li>Cardiologists look after the heart -> echocardiography just looks at the heart </li></ul><ul><li>Critical care doctors look after the entire patient -> so our US scan should look at the patient , not just an organ </li></ul>
  25. 25. Whole-body ultrasound
  26. 26. Current standard of critical care ultrasound <ul><li>LUNG </li></ul><ul><li>IVC </li></ul><ul><li>HEART </li></ul><ul><li>+other regions as appropriate </li></ul>
  27. 27. An important note <ul><li>Cardiologist: 'Why do you want an urgent echo? Echo can't rule out a PE' </li></ul><ul><li>ED physician: 'But this will rule out a massive PE' </li></ul><ul><li>If it's a PE making the patient critically unwell, then it won't be a small one. </li></ul>
  28. 28. Top tip: bloody sick = bloody obvious We're not looking for small pneumothorax or mild CCF ('rule-in', not 'rule-out') If the patient is unstable, the US signs should be obvious
  29. 29. <ul><li>A formal echocardiogram </li></ul><ul><li>It doesn't use M-mode or Doppler </li></ul><ul><li>It doesn't look for subtle disease </li></ul><ul><li>It includes other windows & other organs to synthesize the answer </li></ul><ul><li>The holy grail </li></ul><ul><li>It is not validated in those with minor degrees of illness (eg mild CCF) </li></ul><ul><li>It will sometimes be wrong in the critically ill </li></ul><ul><li>It's just another tool </li></ul>What this isn't
  30. 30. Limitations of critical care US <ul><li>Algorithm: only validated in critically unwell patients </li></ul><ul><li>Patient: suboptimal position & still being resuscitated! </li></ul><ul><li>Time (none!) </li></ul><ul><li>Sonographer </li></ul><ul><ul><ul><li>Image acquisition </li></ul></ul></ul><ul><ul><ul><li>Image interpretation </li></ul></ul></ul>
  31. 31. So: the golden rules 1. 'Resus-only': Patient must be critically unwell: shocked / breathless / peri-arrest. That's because the US signs of some of these diseases are only reliably present if severe eg massive PE, severe pneumonia. If formal studies are needed after resus, get them. 2. Clinical context is paramount. Make a differential diagnosis list before you switch on the machine. All data must be considered (eg FBC with Hb = 4). 3. Only ask questions that you can answer. Leave the fancy stuff (eg valve disease) to others. 4. Repeat scans are crucial during resuscitation & each time clinical picture changes.
  32. 32. Golden rules 5. 90% = 100%: Every test has its limitations. In a periarrest patient, no study will be 100% accurate. If this bothers you, don't practise critical care. RNSH respiratory physician: 'Would you really thrombolyse a critically ill patient with suspected PE on the basis of bedside US?' ED physician answer: 'I spent years doing just that without the benefit of US. Anything that improves my accuracy suits me fine.'
  33. 33. Golden rules 6. When in doubt, be a doctor. You were a clinician before you were a sonographer. If the clinical picture & scan findings don’t agree, believe the clinical picture. ‘ What would I diagnose if I didn’t have an US machine?’
  34. 34. The golden rules 1. 'Resus-only' 2. Clinical context is paramount. 3. Only ask questions that you can answer. 4. Repeat scans are crucial. 5. 90% = 100% 6. When in doubt, be a doctor.
  35. 35. 7. A fool with a stethoscope will be a fool with an ultrasound
  36. 36. Critical care US <ul><li>It’s not the Holy Grail </li></ul><ul><li>Just another tool </li></ul><ul><li>Rapid </li></ul><ul><li>Safe </li></ul><ul><li>Accurate </li></ul><ul><li>Not difficult </li></ul>
  37. 37. Thanks to Daniel Lichtenstein Paul Atkinson Conn Russell Rob Reardon Vicki Noble Russell McLaughlin (for rule #7)
  38. 38. References <ul><li>Blaivas M, Lyon M, Duggal S. A Prospective Comparison of Supine Chest Radiography and Bedside Ultrasound for the Diagnosis of Traumatic Pneumothorax. Acad Emerg Med 2005; 12(9): 844-9. </li></ul><ul><li>Jones AE, Craddock PA, Tayal VS, Kline JA: Diagnostic accuracy of left ventricular function for identifying sepsis among emergency department patients with nontraumatic symptomatic undifferentiated hypotension. Shock 24:513-7,2005. </li></ul><ul><li>Kaul S, Stratienko AA, Pollock SG, Marieb MA, Keller MW, Sabia PJ: Value of two-dimensional echocardiography for determining the basis of hemodynamic compromise in critically ill patients: a prospective study. J Am Soc Echocardiogr 7:598-606,1994. </li></ul><ul><li>Kohzaki S et al. The aurora sign: an ultrasonographic sign suggesting parenchymal lung disease. The British Journal of Radiology 76 (2003), 437–443 </li></ul><ul><li>Lichtenstein D. Whole Body Ultrasonography in the Critically Ill. Springer, 2 nd ed. !st published 1992. </li></ul><ul><li>Lichtenstein D, Meziere G. A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. Intensive Care med 1998; 24(12): 1331-4. </li></ul><ul><li>Lim et al. Ring-down artifacts posterior to the right hemidiaphragm on abdominal sonography: sign of pulmonary parenchymal abnormalities. J Ultrasound Med. 1999; 18: 403-410 </li></ul><ul><li>Moore CL, Rose GA, Tayal VS, Sullivan DM, Arrowood JA, Kline JA: Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Acad Emerg Med 9:186-93,2002. </li></ul><ul><li>Plummer D, Heegaard W, Dries D, Reardon R, Pippert G, Frascone RJ: Ultrasound in HEMS: its role in differentiating shock states. Air Med J 22:33-6,2003. </li></ul><ul><li>Randazzo MR, Snoey ER, Levitt MA, Binder K: Accuracy of emergency physician assessment of left ventricular ejection fraction and central venous pressure using echocardiography. Acad Emerg Med 10:973-7,2003. </li></ul><ul><li>Reissig A, Kroegel C. Transthoracic Sonography of Diffuse Parenchymal Lung Disease: The Role of comet-tail artefacts. J Ultrasound Med 2003; 22(2): 173 -80. </li></ul><ul><li>Rose JS, Bair AE, Mandavia D, Kinser DJ: The UHP ultrasound protocol: a novel ultrasound approach to the empiric evaluation of the undifferentiated hypotensive patient. The American journal of emergency medicine 19:299-302,2001. </li></ul><ul><li>WINFOCUS WORKING GROUP 4. Shock state discussion paper, 3 rd world congress on US in EM and critical care, Paris 2007 </li></ul><ul><li>Yanagawa Y, Nishi K, Sakamoto T, Okada Y: Early diagnosis of hypovolemic shock by sonographic measurement of inferior vena cava in trauma patients. The Journal of trauma 58:825-9,2005. </li></ul><ul><li>http://www.uptodate.com/contents/thoracic-ultrasound-indications-advantages-and-technique?source=preview&selectedTitle=4%7E150&anchor=H1492303#H1492303 </li></ul>
  39. 39. PS Even if I hand't performed an US, I probably still would ’ ve thrombolysed him.

×