The Arrested Patient

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Critical Care Ultrasound Training

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The Arrested Patient

  1. 1. The arrested patient Ad apted from Lichtenstein's SESAME protocol (with permission)
  2. 2. Summary <ul><li>(Ongoing resus) Clinical assessment: formulate the question </li></ul><ul><li>Rapid arrest screen </li></ul><ul><li>Form a working diagnosis </li></ul><ul><li>Continue resuscitation </li></ul><ul><li>Re-scan / monitor progress / further investigations </li></ul>
  3. 3. 1. Formulate the question
  4. 4. 1. Formulate the question <ul><li>Why is the patient arrested: is there a reversible cause? </li></ul><ul><li>b. H ave I successfully intubated? (If ETCO2 not recording) </li></ul>
  5. 5. Is there a reversible cause? Tension PTX Tamponade Toxins Thrombosis (MI) Thromboembolism (PE) Hypovolaemia Hypothermia Hypoglycaemia Hyperkalaemia Hydrogen (acidosis)
  6. 6. Is there a reversible cause? Tension PTX Tamponade Toxins Thrombosis (MI) Thromboembolism (PE) Hypovolaemia Hypothermia Hypoglycaemia Hyperkalaemia Hydrogen (acidosis)
  7. 7. 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?
  8. 8. 2. The arrest screen
  9. 9. Curved probe, abdominal preset Sagittal axis Just like FAST!
  10. 10. A 3-step scan <ul><li>1. Single view heart </li></ul><ul><li>2. Anterior lung fields (1 point each side) </li></ul><ul><li>2. At your discretion: </li></ul><ul><ul><li>IVC (hypovolaemia) </li></ul></ul><ul><ul><li>Abdo (eg AAA / free fluid in trauma) </li></ul></ul><ul><ul><li>Or finish scanning </li></ul></ul>
  11. 11. 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
  12. 12. The arrest scan
  13. 13. Step 1 Single view of heart
  14. 14. What am I looking for? Is there a heartbeat? Pericardial effusion? RV > LV?
  15. 15. Step 1: single view heart <ul><li>Using the curved probe, subcostal view is easiest </li></ul><ul><li>Probe transverse , marker to patient's right </li></ul><ul><li>ID heart (probe angled cephalad) </li></ul><ul><li>Options if you can't obtain an adequate view: </li></ul><ul><ul><li>Try different window (apical, parasternal) </li></ul></ul><ul><ul><li>Try different probe (phased array) </li></ul></ul><ul><ul><li>Get help </li></ul></ul>
  16. 16. Subcostal scan heart
  17. 17. 1
  18. 18. Big RV <ul><li>squashing LV </li></ul><ul><li>It's a PE </li></ul><ul><li>Caveats: </li></ul><ul><li>Is it chronic? Thickened RV wall </li></ul><ul><li>Is it dilated? Intra arrest </li></ul><ul><li>Action: consider thrombolysis </li></ul><ul><li>If in doubt, consider 3-point DVT scan </li></ul>
  19. 19. 2
  20. 20. 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
  21. 21. 3
  22. 22. Active heart, small LV = PEA Pseudo-EMD Hypovolaemia Action: replace volume Find & treat cause = go to step 3
  23. 23. 4
  24. 24. Cardiac standstill Exclude other reversible causes (Hs, Ts) Action: cease CPR
  25. 25. Inadequate view Options: Try another window Try cardiac probe Get help
  26. 26. Step 1: single view heart Big RV S quashing LV Pericardial fluid Cardiac standstill Inadequate view Small volume heart beating ?
  27. 27. 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
  28. 28. Step 1: single view heart Pseudo-EMD Hypovolaemia IV fluid Proceed to step 2
  29. 29. Step 2 Anterior chest
  30. 30. Step 2: anterior chest <ul><li>Probe sagittal, midclavicular line </li></ul><ul><li>Just 1 spot on each side </li></ul><ul><li>Ideally the most elevated portion of chest </li></ul>
  31. 31. TOP TIP: you don ’ t need to be exact <ul><li>If tension PTX, it will fill the hemithorax </li></ul><ul><li>You ’ ll see it anywhere on the anterior chest </li></ul>
  32. 32. Step 2 findings Neither lung is sliding? One lung is not sliding? Both lungs sliding
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. What if there's no lung point? Maybe 1 lung ventilation Maybe a massive PTX ( entire lung collapsed)
  37. 37. 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
  38. 38. Step 3 <ul><li>Hypovolaemia </li></ul><ul><li>What ’ s the cause? </li></ul><ul><li>At your discretion: </li></ul><ul><ul><li>Review clinical picture </li></ul></ul><ul><ul><li>Scan the IVC ( confirm hypovolaemia) </li></ul></ul><ul><ul><li>Scan the abdomen (eg AAA / free fluid in trauma) </li></ul></ul>
  39. 39. Recap: the arrest screen
  40. 40. A 3-step scan <ul><li>1. Anterior lung fields </li></ul><ul><li>2. Single view heart </li></ul><ul><li>3. At your discretion: </li></ul><ul><ul><li>IVC (hypovolaemia) </li></ul></ul><ul><ul><li>Abdo (eg AAA / free fluid in trauma) </li></ul></ul><ul><ul><li>Or finish scanning </li></ul></ul>
  41. 41. 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
  42. 42. 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
  43. 43. Step 3 if hypovolaemia <ul><li>At your discretion: </li></ul><ul><ul><li>Review clinical picture </li></ul></ul><ul><ul><li>Scan the IVC (confirm hypovolaemia) </li></ul></ul><ul><ul><li>Scan the abdomen (eg AAA / free fluid in trauma) </li></ul></ul>
  44. 44. Watch the video again
  45. 45. Further tests? when resuscitation phase completed
  46. 46. Arrest screen: summary <ul><li>Don ’ t get in the way of CPR </li></ul><ul><li>Ten seconds for each step </li></ul><ul><li>Make a working diagnosis </li></ul><ul><li>Re-scan / monitor progress / further investigations </li></ul>

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