Transcript of Case presentation & literature review Two cases.
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- Case presentation & literature review
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- Two cases
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- Dr. Saad Subahi Consultant cardiologist at ALRIBAT university
hospital
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- 46 old male admitted electively to hospital on 12/05/2010 for
lamincectomy
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- MRI showed disc prolapse at L4&5 No significant P.H
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- Next morning (13/05/2010) he had inter laminar discetomy, done
under G.A. Uneventful course
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- 2 nd post-operative day, at 10:30 a.m (Friday) he was seen by
the neurosurgeon Patient was comfortable, apart from minimal
backache Vitals were stable He was advised to mobilize out of
bed
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- Immediately after mobilization patient developed sudden SOB;
taken back to bed, noticed to be sweaty with cold extremities.
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- Soon, prior to any intervention, respiratory and subsequently,
cardiac arrest ensued
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- Advanced cardiac life support was immediately implemented.
After resumption of spontaneous circulation he was transferred to
ICU
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- Before connecting him to M.V. he had second arrest ; CPR (for 3
minutes) -----> Resumption of spontaneous circulation
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- Given 2 liters of N/S because of B.P of 75/45, followed by
dopamine infusion, titrated up to 20mcg/kg/min
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- He was connected to M.V. at 11:0 a.m I attended the patient at
11.30 am
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- Vital signs : pulse 145/min; B.P : 88/52; oxygen sat 99% There
was prominent jugular venous distention.
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- The lungs were clear on auscultation, with normal breath
sounds
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- 12-lead ECG showed sinus tachycardia, S 1 Q 3 T 3 pattern &
RBBB Chest x-ray : normal CBC, Urea & electrolytes were
normal
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- A presumptive diagnosis of massive pulmonary embolism was
made.
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- At 12:15 p.m seen by Dr. Saad & bed side ECHO done
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- Dr Saad ECHO Daignosis Discussed with the neurosurgeon and
started on streptokinase 1.5 million units, over one hour. Events
during streptokinase infusion. Hypotension & bradycardia Severe
biventricular dysfunction ------- adrenaline infusion Improvement
in biventricular function, pulse rate & blood pressure D/C of
adrenaline infusion Maintenance of normal B.P Recovery of RT
ventricular function
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- Diagnosis: Massive PE-induced cardiac arrest + right heart
thrombi-in-transit
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- At 1:30 pm was hemodynamically stable.
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- ECHO, next morning (15 th ), at 8:15 am
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- At 10:0 am : Improvement in BP & O2 saturation, & he
was obeying commands
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- Shifted to spontaneous mode : TV > 300ml, rate 25-28/min
& oxygen saturation 100% on FIO2 0.40
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- Accordingly he was extubated and connected to oxygen by simple
mask (50%)
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- ABG 30 min post extubation : PH : 7.35 PCO2 : 37 mmHg PO2 : 163
mmHg O2 sat : 99% HCO3 : 22 mmol/L BE : -3 mmol/L
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- Time from clinical suspicion to thrombolytic therapy : one
hour
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- 33 years female presented to the emergency room with 2 hours
history of sudden shortness of breath 3/08/2011 at 10.0 am
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- One week prior to presentation she had bilateral fracture of
the tibial shaft (RTA), treated conservatively at home (long leg
casting). Was completely confined to bed.
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- On presentation to A&E Tachypnic : 40/min Pulse : 140/min.
B/P : 70/35 Confused & restless Normal 1+11 heart sounds Chest
: normal auscultation
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- ECG : sinus tachycaria, inverted T- in V1-3 ABG (NRM) : PH :
7.29 PCO2 : 31 mmHg PO2 : 66 mmHg HC03 : 16 mmol/l
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- Chest x-ray : normal
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- High clinical suspicion of massive PE.
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- ECHO : done by Dr Saad, within 15 min from time of
presentation. 1 liter of N/S, followed by dopamine infusion
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- ECHO.
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- Started immediately on IV streptokinase 1.5 million units over
one hour.
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- ARRESTED : CPR was carried and streptokinase infusion was
continued during CPR She was intubated and CPR continued for 12 min
------ > ROSC
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- Transferred to ICU on dopamine infusion Connected to the
ventilator
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- Improvement of oxygenation, but continued to require
inotropics
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- On the same day she had 2 nd arrest at 9:30 pm. CPR for five
minutes ------> ROSC
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- Hospital course AKI required peritoneal dialysis Acute
peritonitis Recovered with a polyuric phase, during which she
developed massive hematuria.
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- On day 5 : massive upper GIT bleeding required blood
transfusion. On day 7 : blocked ETT.
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- Day 11 on mechanical ventilation, she satisfied all extubation
criteria. She was extubated and connected to oxygen by simple
mask.
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- After 29 days in ICU she was transferred to the ward, fully
conscious and oriented with normal renal function; and discharged
home 5 days later.
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- Time from clinical suspicion to thrombolytic therapy : 20
min.
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- Transthoracic ECHO was done at the bedside in critically ill
patients Performed by the clinician who has complete knowledge of
the patients current clinical status Immediately established the
diagnosis and directed towards the appropriate intervention.
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- POLICY STATEMENT Emergency Ultrasound Guidelines Approved
October 2008
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- Focused Cardiac Ultrasound in the Emergent Setting: A Consensus
Statement of the American Society of Echocardiography and American
College of Emergency Physicians J Am Soc Echocardiogr
2010;23:1225-30.
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- Bedside Applications of Ultrasound Cleveland Clinic February
2013
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- Introduction It was unimaginable 100 years ago to be able to
draw a picture from sound.
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- Similarly it was written in The Times in 1834: The medical
profession was unlikely ever to start using the stethoscope because
its beneficial application requires much time and gives a good bit
of trouble.
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- Ultrasound, which is our future stethoscope, has passed through
the same story, as the medical community was initially reluctant to
use it for diagnosing life-threatening conditions by
nonradiologists.
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- Early ultrasonography machines were bulky and their use was
confined to imaging laboratories.
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- Compact and portable ultrasound machines that provide excellent
image quality
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- Has resulted in profusion of bedside applications
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- The concept of an ultrasound stethoscope is becoming a
reality.
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- Ultrasonography has been widely used in cardiology, radiology,
obstetrics, and emergency medicine.
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- More recently, its use has become more widespread in pulmonary
and critical care medicine.
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- Bedside Applications in Pulmonary and Critical Care Medicine
Ultrasonography conducted at the bedside by a clinician, known as
point-of-care ultrasonography, dates back more than twenty years,
but has come to prominence in the last 5-7 years and is spreading
quickly.
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- Has 2 primary uses in pulmonary and critical care
medicine:
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- Procedural guidance Rapid bedside diagnosis in critically ill
patients
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- Ultrasound-guided procedures Some of the common
ultrasound-guided procedures performed in the critical care unit
include
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- Establishing vascular access and monitoring catheters
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- Pericardiocentesis
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- Thoracentesis and pleural catheter placement
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- Paracentesis
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- Lumbar punctures
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- Arthrocentesis
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- Regional anesthesia
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- Ultrasound guided crycothyrotomy and tracheostomy
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- Confirmation of transvenous pacing wire placement
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- Diagnostic applications of Point-of- care ultrasound In
contrast, to formal ultrasound; is performed by the clinician who
is currently caring for the patient and who has complete knowledge
of the patients current clinical status.
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- Interpretation of the ultrasound images and immediate clinical
decisions are made by the clinician conducting the imaging study,
thereby enabling rapid intervention and assessment.
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- The dynamic nature of the techniques and ability to repeat an
examination rapidly, as needed without waiting on an imaging
specialist to perform the examination and interpret it, allows the
individual intensivist to monitor patient progress and effects of
therapeutic interventions.
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- Advantages point-of-care ultrasound Fast Performed at the
bedside Non-invasive Immediate results Repeatable Nonexpensive
without the risk of radiation
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- Point-of-care ultrasound Goal-Directed Echocardiography Lung
Ultrasonography Goal-Directed Abdominal Ultrasonography
Goal-Directed Vascular Ultrasonography
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- Lung Ultrasonography International evidence-based
recommendations for point-of-care lung ultrasound. Intensive Care
Med (2012) 38:577591
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- Pleural effusion
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- Pneumothorax
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- Lung consolidation
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- Interstitial syndrome Pulmonary edema of various causes
Interstitial pneumonia or pneumonitis Diffuse parenchymal lung
disease (pulmonary fibrosis)
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- The four chest areas per side considered for complete eightzone
lung ultrasound examination. These areas are used to evaluate for
the presence of interstitial syndrome.
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- Focused (goal-directed) echo Since its inception over 60 years
ago, echocardiography has remained largely the province of the
cardiologist, providing a tool to evaluate anatomical and
physiological abnormalities of the heart.
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- In recent years, the application of echocardiography has
extended to the diagnosis and monitoring of the critically ill
patients in the general intensive care unit -------------->
Goal-directed Echo
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- Transthoracic Echo, performed at the patients bedside and
interpreted by the treating intensivist to answer specific clinical
questions.
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- The principal role for FOCUS is the time-sensitive assessment
of the symptomatic patient.
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- Clinical Indications for Focused Echo Hypotension/Shock
Dyspnea/Shortness of Breath Chest pain Cardiac Trauma Cardiac
Arrest
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- Goals of the Focused echo in the Emergent Setting Assessment of
global cardiac systolic function and contractility
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- Assessment of the right ventricular function
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- Assessment for the presence of pericardial effusion
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- Intravascular Volume assessment
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- Cardiac arrest Volume Assessment Chest pain
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- Cardiac arrest Successful resuscitation requires potentially
reversible causes to be diagnosed and reversed, and many of these
can readily be diagnosed using echocardiography.
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- Periresuscitation echocardiography provides the only realtime
bedside diagnostic tool that can diagnose some of the potentially
reversible causes of cardiac arrest and can be regarded as
analogous to pulse oximetry or ECG monitoring.
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- Focused echocardiography can be performed within the time frame
allowed during the pulse check of the advanced life support (ALS)
algorithm.
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- A sub-xiphoid probe position has been recommended.
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- The goal of the FOCUS in the setting of cardiac arrest is to
improve the outcome of cardiopulmonary resuscitation by:
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- Determining a cardiac etiology of the cardiac arrest :
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- Tamponade Coronary artery disease Pulmonary embolism
hypovolemia
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- Identifying organized cardiac contractility to help the
clinician distinguish between: -Asystole -Pulseless electrical
activity (PEA) and -Pseudo-pulseless electrical activity,
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- True PEA is defined as the clinical absence of ventricular
contraction despite the presence of electrical activity.
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- Whereas pseudo-PEA is defined as the presence of ventricular
contractility visualized on cardiac ultrasound in a patient without
palpable pulses.
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- Therefore, making the diagnosis of pseudo- PEA can be of
diagnostic and prognostic importance.
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- If mechanical contractility without palpable pulse is
identified (pseudo-PEA), the management can then focus on
hypotension rather than asystolic type resuscitation pathways.
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- Lastly Guiding life-saving procedures at the bedside such as
pericardiocentesis, or evaluate the position of transvenous
pacemaker placement.
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- Volume Assessment In the critically ill, a number of parameters
have been found to indicate severe hypovolaemia. These include
:
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- The presence of a small, hyperkinetic left ventricle (in the
presence of a normal right ventricle) with end-systolic cavity
obliteration.
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- A left ventricular end-diastolic area of less than 5.5 cm2/m2
body surface area.
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- A small inferior vena cava (diameter