Emergency Medicine Echocardiography

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Slide 1 :

emergencyultrasound.org.uk The ACES scan Ultrasound in hypotension Richard Kendall Paul Atkinson

Slide 2 :

emergencyultrasound.org.uk Abdominal (and) Cardiac Evaluation (with sonography in) Shock The ACES scan

Slide 3 :

emergencyultrasound.org.uk The ACES scan Extension of more established emergency medicine uses of ultrasound Abdominal component Cardiac component (Peripheral component)

Slide 4 :

emergencyultrasound.org.uk Case 1 ‘Red call’ Elderly female – collapsed and absent radial pulse Arrives – peri-arrest Groaning Initial resuscitation ACES scan

Slide 5 :

emergencyultrasound.org.uk Case 1 Huge AAA, tender Terminal care instituted

Slide 6 :

emergencyultrasound.org.uk Case 2 ‘Red call’ 62 year old man Hypotension, epigastric pain Unwell ?AAA 10 minutes

Slide 7 :

emergencyultrasound.org.uk Case 2 BP 74/54, Pulse 110, clammy Initial resuscitation underway ACES scan

Slide 8 :

emergencyultrasound.org.uk Abdomen No AAA

Slide 9 :

emergencyultrasound.org.uk Abdomen No free fluid

Slide 10 :

emergencyultrasound.org.uk Abdomen - IVC Slight collapse on inspiration

Slide 11 :

emergencyultrasound.org.uk Cardiac - subcostal No pericardial effusion Hyperdynamic Not small RV not dilated

Slide 12 :

emergencyultrasound.org.uk CXR Fluid challenge IV antibiotics IJ line (us control) ICU

Slide 13 :

emergencyultrasound.org.uk ACES scan Aim is to help identify the likely cause of hypotension

Slide 14 :

emergencyultrasound.org.uk Causes of Hypotension Hypovolaemia Obstructive (tamponade) Obstructive (PE) Cardiogenic Distributive (septic)

Slide 15 :

emergencyultrasound.org.uk Hypovolaemia Two aims of ACES scan:- To establish existence of hypovolaemic state IVC ‘collapse index’ Cardiac Small chamber size ‘small heart’ Aggressive wall motion ‘hyperdynamic’ To identify possible causes AAA Free fluid (haemoperitoneum)

Slide 16 :

emergencyultrasound.org.uk Tamponade Aims of ACES scan to:- Identify pericardial effusion Collapse RA/RV during diastole = tamponade

Slide 17 :

emergencyultrasound.org.uk PE ACES scan aims to identify:- RV dilatation RV hypokinesis Paradoxical septal motion IVC distension (Peripheral views for DVT)

Slide 18 :

emergencyultrasound.org.uk Cardiogenic ACES scan aims to identify gross abnormalities of cardiac:- Size Normal Small Dilated Motion Normal Hyperdynamic Hypodynamic Hypodynamic myocardium = cardiogenic

Slide 19 :

emergencyultrasound.org.uk Sepsis ACES scan aims to identify:- Hyperdynamic left ventricular function Hyperdynamic heart has sensitivity of 33% and a specificity of 94% for sepsis Diagnostic accuracy of left ventricular function for identifying sepsis among emergency department patients with non traumatic symptomatic undifferentiated hypotension Jones A et al Shock 2005 Dec;24(6) :513-7

Slide 20 :

emergencyultrasound.org.uk ACES scan - 6 windows Cardiac IVC Aorta RUQ LUQ Pelvis

Slide 21 :

emergencyultrasound.org.uk IVC and collapse index Relationship between IVC pressure and RA pressure Identify IVC Measure in inspiration and expiration M mode Calculate ‘collapse index’

Slide 22 :

emergencyultrasound.org.uk IVC and collapse index

Slide 23 :

emergencyultrasound.org.uk Collapse Index Inspiration – IVC collapses slightly Expiration – IVC maximal diameter

Slide 24 :

emergencyultrasound.org.uk Collapse Index (CI) Max diameter – Min diameter CI = x 100% Max diameter Maximum diameter - expiration Minimum diameter - inspiration

Slide 25 :

emergencyultrasound.org.uk Collapse Index CI > 50% = RA pressure < 10mmHg CI < 50% = RA pressure > 10mmHg Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava Kircher BJ et al Am J Cardiol 1990 Aug 15;66(4):493-6

Slide 26 :

emergencyultrasound.org.uk ACES scan - subcostal Pericardial effusion Gross assessment of cardiac wall motion Normal Hypodynamic Hyperdynamic Gross assessment of cardiac chamber size

Slide 27 :

emergencyultrasound.org.uk ACES scan – additional views Thoracic views – parasternal, apical Augment subcostal view (Peripheral views – DVT)

Slide 28 :

emergencyultrasound.org.uk Summary ACES scan

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emergencyultrasound.org.uk. The ACES scan. Ultrasound in hypotension. Richard Kendall. Paul Atkinso more emergencyultrasound.org.uk. The ACES scan. Ultrasound in hypotension. Richard Kendall. Paul Atkinson. emergencyultrasound.org.uk. Abdominal ... less
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